Coronial
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's e…

obstetricsemergency medicinedelay
WAhome2015-06-08

Inquest into the Death of Baby C

0y · Male·Group B Streptococcal infection and meconium aspiration with early bronchopneumo…

… Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had declined GBS screening an…

midwiferyobstetricsdiagnosticdelay
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a…

paediatricsemergency medicinesystemmedicationfurosemide
SAhome2008-02-11

Coroner's Finding: LYDEN-BAKER Elizjah Monique Ivy

0y · Female·undetermined; possible suffocation not definitively established at autopsy

A 4-week-old neonate died at home with undetermined cause, though suffocation on a soft pillow was considered possible. The infant was born p…

neonatologypaediatricscommunicationsystemmorphine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

…al wires), and the mother's clear inability to cope without support. Key missed opportunities were: no pre-birth safety planning after the termination attempt; discharge home despite significant concerns; and failure to…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia…

obstetricsmidwiferydiagnosticcommunication
NThome2005-06-06

Inquest into the death of Alison Woods

5y · Female·chronic hydrocephalus

…5-year-old girl with severe congenital brain damage, spastic quadriplegia, and chronic hydrocephalus since birth, died at home in Katherine on 2 July 2004. She required constant medication and full-time care for daily s…

paediatricsneurologyanti-epileptic medications
VIChospital2013-06-12

Finding into death of Findings Adang Akot

9y · Female·intercurrent pneumonia/respiratory infection in a setting of chronic lung diseas…

… that the Royal Children's Hospital provided appropriate clinical care throughout her hospitalisation from birth. No protective concerns or medical management issues were identified. The death occurred in the context of…

paediatricsrespiratory medicine
QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

Baby M was born at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite …

neonatologyparamedicinediagnosticdelay
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

…sfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical …

obstetricsneonatologycommunicationsystemmagnesium sulphate
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

…lopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a country hospital. Critical failures included: (1) discharge of the mother from…

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
NSWhome2018-11-14

Inquest into the death of Jaxon McGrorey-Smith

0y · Male·neonatal encephalopathy due to perinatal compromise

…rolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging confirming severe bilateral brain injury. After detailed discussions with the parents re…

neonatologyneurologyoxytocin
NSWhome2019-02-26

Inquest into the death of Emily

Female·self-inflicted death

Emily, a child in out-of-home care since infancy, died by suicide in 2014. She had early childhood trauma, attachment difficulties, and a…

psychologypsychiatrycommunicationsystem
QLDhospital2021-01-27

Brown, Tara Matekino - Non-inquest findings

24y · Female·Head injury from repeated blunt force trauma

A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…

emergency medicineintensive carediagnosticcommunication
VIChome2012-07-06

Finding into death of Baby N

4y · Male·Sudden Infant Death Syndrome (Category 2)

…The infant had undiagnosed recurring respiratory issues (suspected reactive airways disease or asthma from birth) but had been sleeping on a shared sleep surface with his mother. The coroner emphasised that shared sleep…

paediatricsforensic medicinecommunicationsystem
VIChome2020-11-20

Finding into death of Baby S

1y · Male·head injury

…nted with concerning bruises shortly before death. Despite extensive child protection involvement prior to birth and ongoing concerns about maternal drug abuse, family violence, and the unassessed partner, critical gaps…

paediatricsgeneral practicediagnosticcommunicationheroin
WAcommunity2011-02-28

Inquest into the Death of Collins

0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease

…Griffin, failed to contact a doctor despite alarming vital signs, instead advising parents to take the baby home with minimal monitoring instructions. The baby deteriorated overnight and died the following morning. The C…

emergency medicinegeneral practicediagnosticcommunication
NSWhome2025-05-30

Inquest into the Death of K.P.

3y · Male·unascertained

…ew after hospital discharge, inadequate engagement with the mother regarding her circumstances, and lack of home visits by caseworkers for six weeks prior to death. The cause of death remains unascertained. Key clinical …

paediatricspsychiatrysystemcommunicationcannabis
TAShome2015-05-27

Coroner's Finding: Pearce, Jasmine Rose

0y · Female·suffocation under bedding

Jasmine Rose Pearce, aged 11 months, died from suffocation under bedding in her family home on 27 January 2013. Her parents engaged in sexual activity on the bed where Jasmine was sleeping while unde…

paediatricsemergency medicinesystemdelaycannabis
VIChome2024-11-28

Finding into death of Child 1, Child 2, Child 3, Child 4

Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…

This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…

paediatricspsychiatrydiagnosticcommunicationmethamphetamine

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.