Coronial

39 results for severe developmental delay

TAShospital2021-03-19

Coroner's Finding: Master T

3y · Male·Hypoxic brain injury secondary to cardiorespiratory arrest, possibly secondary t…

…m hypoxic brain injury secondary to cardiorespiratory arrest, likely due to aspiration pneumonitis. He had severe congenital abnormalities including holoprosencephaly with VP shunt, anal atresia, oesophageal atresia, and…

paediatricsintensive careparacetamol
NSW2025-02-28

Inquest into the death of Cameron De Vries

20y · Male·Drowning precipitated by a seizure

Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a b…

emergency medicineneurologydiagnosticsystemranitidine
NThome2003-07-31

Inquest into the death of Queenie Michaels

11y · Female·pneumonia complicating cytomegalovirus embryopathy

Queenie Michaels, an 11-year-old Aboriginal girl with cytomegalovirus embryopathy and severe physical and cognitive disabilities, died from pneumonia at home while in government care. She had been fo…

paediatricsneurologyanti-convulsants
VIChome2020-01-14

Finding into death of H B

8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cac…

HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Betwee…

paediatricsneurologydiagnosticdelaylevetiracetam
WAhospital2019-07-30

Inquest into the Death of Child KT (Name Subject to Suppression Order)

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

…dical needs including chronic respiratory disease, requiring PEG feeding and multiple medications. After a severe respiratory event in 2015 requiring ICU admission and ventilation, a palliative care plan was established …

paediatricsintensive caresystemmorphine
QLDhospital2023-02-13

Hunter- Non-inquest findings

8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…

…ty; failure to seek senior surgical review despite overnight clinical deterioration and parental concerns; delayed paediatric involvement; poor pain assessment not accounting for autism; missed opportunity to score obse…

surgerypaediatricsdiagnosticcommunicationondansetron
WAhome2024-04-04

Inquest into the Death of Child LT (Name Subject to Suppression Order)

11y · Male·unascertained

An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex ca…

paediatricscardiologycommunicationsystemcocaine
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
QLDhome2025-06-25

Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

0y · Male·Severe acute dehydration and acute malnutrition

An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day d…

paediatricsemergency medicinediagnosticsystemmethamphetamine
NThospital2024-12-06

Inquest into the death of Baby G

0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…

Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…

neonatologypaediatricsdiagnosticsystem
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and str…

general practiceemergency medicinediagnosticdelayparacetamol
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

…remature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associated lung and bowel dis…

neonatologypaediatricsdiagnosticcommunication
VICcommunity2014-03-19

Finding into death of Darren Brett Kingma

29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…

A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor b…

emergency medicineradiologydiagnosticcommunicationclonazepam
NSW2018-02-16

Inquest into the death of Carney Schultz

28y · Female·complications of epilepsy

Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seiz…

neurologygeneral practicecommunicationsystemmidazolam
NSWout-of-home care2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

…on emotional regulation and impulse control. Prevention would have required earlier comprehensive neurodevelopmental assessment, continuity of therapeutic relationships, and integrated child protection and health servic…

psychiatrypaediatricssystemdelay
QLDcommunity2010-09-07

Simpson-Willson, John Douglas

56y · Male·head injuries inflicted by blunt force trauma

…is meeting legal criteria, he could not be involuntarily detained. The case illustrates how prisoners with severe mental illness and intellectual disability fall between service gaps due to funding shortfalls, poor coord…

psychiatrycorrectional healthdiagnosticcommunication
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI o…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
NSWcommunity2022-10-21

Inquest into the death of Riley Christopher Shortland

8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorw…

occupational therapypsychologydiagnosticcommunication

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