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VIChospital2016-10-24

Finding into death of Child A

3y · Male·thrombotic microangiopathy

A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…

paediatricsemergency medicineondansetron
QLDhospital2016-05-06

Sweet, Lilli

6y · Female·Brain stem herniation due to pneumococcal meningitis

Lilli Sweet, a 6-year-old asplenic child with hereditary spherocytosis, died from pneumococcal meningitis with brain stem herniation. She presented to Nambour Hospital ED with vomiting, diarrhea, and headache on 25 Augus…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIChospital2015-12-10

Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…

Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…

ENT surgerypaediatric surgerymedicationcommunicationtramadol
VIChome2014-03-17

Finding into death of Marcus Michael Christopher Charles

0y · Male·Complications of small bowel obstruction due to post operative adhesions

Marcus Charles, a 3-month-old neonate, died from small bowel obstruction due to postoperative adhesions following earlier surgical repair of oesophageal atresia and duodenal atresia. On 4 November 2006, paramedics attend…

emergency medicineparamedicinediagnosticcommunicationranitidine
VIC2013-08-19

Finding into death of TH

2y · Female·Blunt force injury to the abdomen

A two-year-old girl died from blunt force injury to the abdomen, sustaining internal injuries including pancreatic rupture, jejunal rupture, and liver trauma with significant intra-abdominal hemorrhage. Evidence indicate…

paediatric surgeryemergency medicinedelaysystem
VIChospital2013-06-12

Finding into death of Findings Adang Akot

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

Adang Akot was a 9-month-old infant with chronic lung disease and subglottic stenosis who died from intercurrent pneumonia and respiratory infection at the Royal Children's Hospital. The coroner was satisfied that the Ro…

paediatricsrespiratory medicine
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …

general practicegeneral medicinediagnosticcommunicationlamotrigine
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

8y · Male·Septic shock consequent on burst appendix with peritonitis

Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…

emergency medicinegeneral practicediagnosticcommunicationampicillin
QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
NThospital2011-06-01

Inquest into the death of Damon Cabiddu

4y · Male·acute suppurative peritonitis following rupture of an inflamed vermiform appendi…

A 4-year-old Aboriginal boy with autism presented to emergency with vomiting and fever. Appendicitis was considered as a primary diagnosis from admission. Clinical examination was challenging due to communication difficu…

paediatricsemergency medicineparacetamol
VIChospital2011

Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…

gastroenterologyanaesthesiadiagnosticproceduralphytomenadione
SAhospital2010-09-27

Coroner's Finding: ORMEROD Madison Hayley

4y · Female·consequences of incarcerated congenital left diaphragmatic hernia

Madison Ormerod, aged 4 years, died from incarcerated congenital left diaphragmatic hernia. Over 3 months before death, she presented with persistent vomiting and abdominal pain to her GP and paediatrician. The paediatri…

general practicepaediatricsdiagnosticdelay
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clini…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition
VIChospital2003-02-01

AINALIDIS Taylor

0y · Male·Cardiorespiratory failure due to failure of anaesthetic rebreathe bag

Taylor Ainalidis, aged 3 weeks, died on 21 June 2000 at the Royal Children's Hospital following cardiorespiratory failure during resuscitation after surgery for Tetralogy of Fallot. The primary cause was failure of an an…

cardiothoracic surgeryanaesthesiasystemprocedural
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic

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