Coronial

192 results for child abuse

VIChome2021-05-15

Finding into death of Ms ZT

27y · Female·Multiple sharp force injuries

…e injuries. The coroner's investigation revealed a prolonged pattern of severe domestic violence, physical abuse, emotional control, and social isolation. Multiple service providers—including Campbell Page Employment Se…

communicationsystem
ACThome2021-04-29

Inquest into the death of Bradyn Stuart Dillon

9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…

… to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him despite numerous concerning reports spann…

paediatricsgeneral practicediagnosticcommunicationmethamphetamine
SAhome2016-01-28

Coroner's Finding: NAPIER Ebony Simone

0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father

…her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian child protection authority (Families SA) did not obtain information about Bradley Napier-Tucker's documented his…

paediatricsradiologydiagnosticcommunicationcannabis
WAhospital2020-09-23

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

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

…ant infants is a 'red flag' requiring specialist paediatric assessment; GPs must directly communicate with child protection services when concerns arise and should not offer reassurance letters based on incomplete infor…

paediatricsgeneral practicediagnosticcommunicationtopiramate
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

…ing discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver disease. Critical gaps were identified in the child protection system: t…

paediatricspsychiatrysystemcommunicationalcohol
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

… violence risk factors including potential coercive control by the father, social isolation, and emotional abuse. While Ms Thomas had been identified as the alleged perpetrator in initial police/Child Protection involve…

general practicepsychiatrydiagnosticsystem
NSWhospital2025-05-01

Inquest into the death of DB

2y · Female·sequelae of blunt force head and spinal cord injuries

… audio Helpline recordings to assist caseworkers in assessing complaint credibility. Key lesson: statutory child protection responsibility cannot be delegated; systemic failures in assessment, supervision, and decision-…

paediatricsemergency medicinediagnosticsystem
QLDhome2021-01-22

Cobb, Tyrell - Non-inquest findings

4y · Male·Intra-abdominal injuries from blunt force trauma (ruptured duodenum and lacerate…

…ntable. This case highlights the importance of recognising patterns of injury, responding appropriately to children presenting with concerning symptoms, and mandatory reporting obligations.

paediatricsemergency medicinedelaysystem
VIChospital2018

Finding into death of Anthony Sean Jenkins

49y · Male·Hypoxic ischaemic brain injury complicating neck compression in the circumstance…

…d man with significant alcohol consumption, died by hanging on 30 August 2017 after police notified him of child sexual abuse allegations made by his daughter on 23 August 2017. He was found unconscious on 27 August 201…

intensive carepalliative caresystemalcohol
QLDhome2020-06-02

Lee, Mason Jet

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

…on was admitted to hospital in February 2016 with severe perianal injuries and cellulitis, consistent with abuse and neglect. Despite clear medical evidence of serious harm, the Department of Child Safety failed fundame…

paediatricsinfectious diseasesdiagnosticsystemmethamphetamine
QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

…ents who were both morphine-dependent. The coroner found that one parent deliberately gave morphine to the child, possibly to keep her asleep. Key clinical and systemic failures included: the prescribing doctor (Dr S.) …

paediatricsgeneral practicemedicationdiagnosticmorphine
SAhome2015-04-09

Coroner's Finding: VALENTINE Chloe Lee

4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…

…h Chloe over her nearly 4.5-year life. Major failures identified include: systemic non-compliance with the Children's Protection Act (particularly section 20(2) regarding mandatory drug assessments), failure to utilise …

paediatricsforensic medicinediagnosticsystemmethamphetamine
NSWhome2025-01-17

Inquest into the death of BG

0y · Male·Concussive brain injury

…ry caused by intentional head trauma inflicted by his mother's partner in a domestic violence context. The child had multiple bruises, bite marks, and subdural haemorrhages. A critical failure occurred when the Departme…

forensic medicinepaediatricssystemcommunication
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents as both perpetrator and victim in rel…

psychiatrygeneral practicecommunicationsystemvenlafaxine
NTcommunity2020-12-15

Inquest into the death of Master W, Miss B and Master JK

volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…

This inquest examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote …

psychiatryaddiction medicinediagnosticsystempetrol
VIChome2012-01-23

Finding into death of Linda Parker

53y · Female·Multiple stab wounds inflicted by an unknown assailant

…al lesson relates to healthcare professionals' responsibilities: the family GP witnessed Ms Sweet's verbal abuse of Ms Parker but there is no record of intervention or referral to support services. Early identification …

forensic medicinegeneral practicecommunicationsystemcitalopram
QLDhome2013-04-16

Borusiewicz, Luke Anthony

2y · Male·head injury due to accidental fall from bed

…m into care on 24 December 2008 after rigorous assessment and demonstrated competence with multiple foster children. On the morning of his death, Luke returned from a scheduled contact visit with his father. Joy, who ha…

emergency medicineneurosurgery
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

…12 months), and did not consistently use prescribed treatment. The parents, both struggling with substance abuse, were unable to implement required lifestyle changes. Community Services received multiple reports but fai…

respiratory medicineendocrinologycommunicationsystemmethadone
TAShome2016-07-22

Coroner's Finding: ADT

0y · Female·subdural haemorrhage, intracranial haemorrhage and oedema caused by severe shaki…

…ng previous injuries during the preceding week. The coroner found no deficiency in healthcare response—the child's injuries were hidden from medical staff until her presentation, at which point appropriate emergency man…

neonatologypaediatricscannabis
VIChome2012-07-05

Finding into death of Angela Jade Bannister

1y · Female·Chest injuries

…uries. This case highlights the critical importance of careful assessment of unexplained injuries in young children, recognition of inconsistencies in parental accounts, and robust communication with child protection au…

emergency medicinepaediatricscommunicationibuprofen

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