545 results
3y · Male·unascertainable; malnourishment was a significant contributing factor
Bradley Frederick Whitehouse, aged 3 months, died on 10 February 2008 from causes ruled unascertainable. He was severely malnourished and emaciated at death, having deteriorated dramatically over the final month of life.…
2y · Female·pneumonia in a toddler with enlarged tonsils and presence of codeine in blood
Elanur Koc, a 2-year-old with a history of recurrent throat infections and enlarged tonsils, died from pneumonia. Significant codeine was detected in her blood, urine, liver, and stomach contents, with codeine also prese…
1y · Female·Pulmonary hypertension and right heart failure secondary to total anomalous pulm…
Mykayla Marshall, a 15-month-old child with complex congenital heart disease including total anomalous pulmonary venous drainage, pulmonary vein stenosis, and septal defects, died at home from pulmonary hypertension and …
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
Edward Thomas Collins was a 3-month-old neonate with surgically corrected congenital heart disease (Total Anomalous Pulmonary Venous Drainage) who died on 14 January 2007 from cardiac arrhythmia. On 13 January 2007, he p…
17y · Male·Epilepsy with contributing factors of cerebral palsy and intellectual disability
Taner Kirim, a 17-year-old with cerebral palsy, intellectual disability and poorly controlled epilepsy, died in his sleep at a residential care facility. He was in out-of-home care through the Department of Human Service…
0y · Female·Spinal Muscular Atrophy - Type 1
Kasey Gower-Moyle was born in September 2008 and diagnosed with terminal spinal muscular atrophy type 1 in March 2009, a severe neuromuscular disorder. From April 2009, she received 24-hour inpatient palliative care at R…
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…
2y · Female·drowning
A 2-year-old girl drowned in a backyard swimming pool after gaining access through a sliding security door with a deliberately disabled lock. The father had tampered with and rendered non-functional the locking mechanism…
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
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 of her spine. A paediatric…
2y · Male·Hypoxic Ischaemic Brain Injury in circumstances of Ligature strangulation (Blind…
Lachlan McCann, a healthy 2-year-old, died from hypoxic ischaemic brain injury following ligature strangulation by a blind cord. While playing on a couch beneath a window, he became entangled in an unsecured Holland blin…
2y · Female·compression of the neck as a result of having become entangled in a blind cord
Rosalind Smith, a healthy 2-year-old, died from neck compression after becoming entangled in a Holland blind cord while attempting to look out a bedroom window. The cord was unsecured and hung at 870mm from the floor, ac…
4y · Female·aspiration of vomitus and its treatment due to rheumatic carditis against a back…
A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21,…
3y · Male·asphyxia secondary to epilepsy
Jayden Lynch, aged 3, died on 15 December 2008 while attending family day care in Yamba, NSW. He had epilepsy managed by a paediatrician with medications (Tegratol, Trileptac) and emergency rectal diazepam. On the day of…
Female·Multiple: undetermined consistent with overlaying (Naomi Kade); undetermined pos…
This inquest examined five infant deaths (aged 1 month to 10 months) occurring between July 2007 and November 2008, all involving co-sleeping with adults. Deaths were attributed to undetermined causes, possible overlayin…
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…
Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…
Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extract…
52y · Female·Aspiration pneumonia complicating end-stage dementia
Eileen Wilson, a 52-year-old woman with Down's syndrome and Alzheimer's dementia, died from aspiration pneumonia after 27 days of hospitalisation. She was transferred to hospital in early July 2009 after DHS staff noted …
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…
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