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QLDhospital2020-08-26

Baby C - non-inquest findings

0y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investig…

neonatologyobstetricsdiagnosticproceduralmorphine
QLDhome2020-06-02

Lee, Mason Jet

1y · Male·Abdominal injuries (perforation of small bowel and mesentery with peritonitis pr…

Mason Lee, aged 22 months, died on 11 June 2016 from abdominal injuries inflicted by his mother's partner, William O'Sullivan, combined with severe neglect. Mason was admitted to hospital in February 2016 with severe per…

paediatricsinfectious diseasesdiagnosticsystemmethamphetamine
QLDhome2020-05-06

T and P - Non-inquest findings

Female·Drowning

Two young sisters, aged 4 and 3 years, drowned in a residential swimming pool while unsupervised. Both parents were present in the home but inattentive—the mother was asleep in the bedroom while the father was using his …

paediatricsemergency medicinesupervisionsystem
QLDhome2019-04-17

Tran, Lucas

0y · Male·Sudden Infant Death Syndrome (SIDS) Category II

Lucas Tran, a five-month-old infant in family day care, died suddenly on 18 November 2015. Despite resuscitation attempts, he could not be revived. Autopsy found no specific pathology; death was attributed to Sudden Infa…

paediatricsemergency medicinesystemcommunication
QLDhospital2018-09-21

Baby M

0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…

Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…

obstetricsmidwiferydiagnosticmedicationantibiotics
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …

general practiceemergency medicinediagnosticdelaymupirocin
QLDhospital2016-11-07

Bower, Malaki Ron - Non-inquest findings

2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…

A 2-year-old boy presented to hospital with croup (parainfluenza 1 laryngotracheobronchitis) on 13 July 2013. He was given nebulised adrenaline by ambulance and dexamethasone at hospital, then discharged after only 3 hou…

emergency medicinepaediatricsdiagnosticcommunicationnebulised adrenaline
QLDcommunity2016-09-10

C, a child aged 14 - Non-inquest findings

14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foe…

A 14-year-old girl with foetal alcohol syndrome, autism, and intellectual impairment died from hypoxic-ischaemic encephalopathy following choking on food during a community outing. She had been in state care since infanc…

paediatricsemergency medicinesystemcommunication
QLDhospital2016-06-03

James, Kesler Lee

5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…

A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the s…

paediatricsintensive carediagnosticcommunicationfurosemide
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
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

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

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…

obstetricsneonatologycommunicationsystemmagnesium sulphate
QLDhome2015-12-18

T, a child aged 15 months

1y · Male·Hypoxic ischaemic encephalopathy due to drowning

A 15-month-old child drowned in a partially-filled, unmaintained home swimming pool after the entrance gate was propped open with a length of wood. The child was playing in the yard while his mother's attention was occup…

paediatricsemergency medicinesupervisionsystem
QLDhospital2015-11-03

Steer, Summer Alice

4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…

A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…

general practiceemergency medicinediagnosticcommunicationmetronidazole/flagyl
QLD2015-10-09

(P) a thirteen year old girl

13y · Female·Multiple injuries due to motor vehicle accident

A 13-year-old Aboriginal girl in residential care absconded with a vehicle after an extended violent altercation with youth workers and died in a high-speed motor vehicle crash. She had extensive trauma history, PTSD, re…

paediatricspsychiatrysystemdelay
QLDcommunity2015-06-09

JE and JJ, two 16 year old boys

16y · Male·Hanging (ligature compression of neck)

Two Indigenous young men, JE (16 years) and JJ (16 years), both died by hanging within four months during a suicide cluster in Mackay, Queensland in 2008. JE's death was impulsive, occurring after paint sniffing and alco…

psychiatryemergency medicinediagnosticcommunicationalcohol
QLDhospital2015-05-08

Marr, Hunter Campbell

9y · Male·asthma - acute episode of asthma which became increasingly resistant to Ventolin

Hunter Campbell Marr, a 9-year-old with episodic asthma, was admitted on 2 January 2014 with asthma exacerbation. His parents denied or minimised his asthma diagnosis despite previous PICU admission in 2011. During the J…

paediatricsrespiratory medicinecommunicationsystemsalbutamol
QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

Tamiya Calais Lievesley, a six-month-old infant, died from morphine toxicity on 2 March 2004. She ingested a fatal dose of morphine, likely administered by one of her parents who were both morphine-dependent. The coroner…

paediatricsgeneral practicemedicationdiagnosticmorphine
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…

obstetricspaediatricscommunicationdelay
QLD2014-12-12

Chen, Ruby Yan

3y · Female·massive air embolism

Ruby Chen, 3 years old, died from massive air embolism during aeromedical transfer from Blackwater to Rockhampton Hospital. The fatal sequence occurred when a paramedic re-spiked a partially-used IV saline bag (containin…

retrieval medicineemergency medicineproceduralsystem
QLDcommunity2014-12-12

Hicks, Indianna Rose

5y · Female·Sudden Infant Death Syndrome (Classic Type 1a)

A 5-month-old infant died suddenly at a family day care facility on her first day of formal care, with autopsy findings consistent with Sudden Infant Death Syndrome (SIDS). The child had been fully swaddled with arms enc…

paediatricsforensic medicinesystemcommunication

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