Coronial
VIChome2024-11-21

Finding into death of Baby S

7y · Male·Hypoxic ischaemic encephalopathy in the setting of a breech delivery

A neonate born at home in breech presentation without medical assistance suffered hypoxic ischaemic encephalopathy and died at 7 days old. The mother had been counselled by hospital obstetricians about risks of home bree…

obstetricsemergency medicine
VICcommunity2022-10-13

Finding into death of Krystal Fraser

23y · Female·Death by homicide; medical cause unable to be determined due to body not being l…

Krystal Lee Fraser, 23 years old and nine months pregnant, disappeared from Pyramid Hill, Victoria on 20 June 2009 and has never been found. The coroner concluded she died on or shortly after 21 June 2009 near Leitchvill…

obstetricscommunicationsystemcannabis
NSWhome2017-08-15

Inquest into the death of Alyce POLLETT

20y · Female·unascertained

Alyce Pollett, a 20-year-old pregnant woman, was found dead in her bed on 14 July 2011 after being unwell for approximately one week with flu-like symptoms. Autopsy findings were concerning for possible asphyxia due to n…

obstetricsgeneral practicecommunicationsystem
SAhospital2023-06-30

Coroner's Finding: Vanin, Levi Shane

29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…

…citation failure. The infection was likely present for several days before birth and undetectable during pregnancy. Clinical management of antenatal period, labour, delivery, and neonatal resuscitation was appropriate a…

obstetricsneonatologydinoprostone
NSWcommunity2025-09-29

Inquest into the disappearance and suspected death of Leisl Smith

23y · Female·Unknown (homicide)

Leisl Smith, 23 years old, disappeared on 19 August 2012 after being picked up by James Church from Tuggerah Railway Station. She was never found. The coroner concluded on the balance of probabilities that Church killed …

NThome

Inquest into the death of Sudden unexpected death of an infant

0y · Female·Sudden unexpected death of an infant (SUDI) from viral pneumonitis (Rhinovirus a…

A 5-week-old Aboriginal infant with intrauterine growth restriction (IUGR) died of sudden unexpected infant death (SUDI) caused by viral pneumonitis from rhinovirus and enterovirus. She was found unresponsive at a remote…

obstetricspaediatrics
NSWhospital2023-08-22

Inquest into the death of AN

0y · Female·Methylamphetamine toxicity

A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…

neonatologypaediatricsmethamphetamine
NSW2022-07-22

Inquest into the death of Daniel KING

33y · Male·multiple gunshot wounds to the head, trunk and limbs

Daniel King died following multiple gunshot wounds sustained during a police operation. He had acquired a firearm and attended three locations in western Sydney, discharging it before arriving at Penrith Police Station w…

psychiatryneurologysystemcocaine
NThome2011-05-13

Inquest into the death of Marlon Aidan Clancy

8y · Male·accidental suffocation (mechanism unknown)

An eight-week-old Aboriginal male infant died from accidental suffocation in circumstances of co-sleeping with his heavily intoxicated mother, young sister, and an adult male on a soft mattress with pillows. The coroner,…

paediatricspathologycommunicationalcohol
WAcommunity2016-01-06

Inquest into the Death of Gonda Alexandra SMITH

64y · Female·multiple injuries sustained in head-on motor vehicle collision

A 64-year-old remote area nurse died in a head-on vehicle collision on a remote unsealed road whilst transporting a critically ill patient to hospital for emergency care. The coroner found that the primary cause was driv…

emergency medicineoccupational and environmental healthproceduralsystem
WAhome2021-08-26

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

0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…

neonatologynephrology
VIChospital2017-01-24

Finding into death of Baby XY

0y · Female·Perinatal asphyxia

…inical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes during pregnancy due to a pathology laboratory system error (two of three glucose tolerance test results not downloaded t…

anaesthesiaforensic medicinediagnosticsystembenzyl penicillin
QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…

…ncephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneous rupture of membranes and underwent labor induction. During labor, cardiotocog…

obstetricsmidwiferydiagnosticcommunicationoxytocin
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

…after stepping in front of a train on 16 November 2010. He had recently been distressed about a reported pregnancy with a girlfriend and experienced a rapid deterioration following his girlfriend ending their relationsh…

psychiatrygeneral practicediagnosticcommunicationtemazepam
NSWhome2016-09-14

Inquest into the death of NA

0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …

A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…

general practiceobstetricscommunicationsystem
VIChospital2024-11-21

Finding into death of Baby LT

2y · Male·Pneumonia

A 2-month-old Aboriginal infant died of pneumonia on 17 July 2019. Key clinical lessons: (1) Fever in infants <3 months requires careful evaluation per RCH guidelines, including investigations and admission for observati…

paediatricsemergency medicinediagnosticcommunication
ACThospital2009-04-28

Inquest Into The Death Of Stacey And Courtney Meas

Female·Stacey Meas: severe closed head injury from motor vehicle collision. Courtney Me…

Two deaths resulted from a motor vehicle collision caused by a driver with poorly managed insulin-dependent diabetes. Stacey Meas, a pregnant woman, died from head injuries sustained when the driver's car struck hers at …

endocrinologyemergency medicinesysteminsulin
NSWhospital2026-03-17

Inquest into the death of Gia Lam

32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…

A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…

obstetricsmidwiferydiagnosticcommunication
VIChospital2012-07-16

Finding into death of Dishita Madamshetty

0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…

A full-term neonate born after induction of labour died from hypoxic brain injury secondary to meconium aspiration syndrome and chorioamnionitis. The baby presented in poor condition at delivery with thick meconium prese…

obstetricsneonatologydiagnosticcommunication
VIChome2026-05-29

Finding into death of Baby R

0y · Male·Perinatal hypoxia

Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…

obstetricsmidwiferydiagnosticcommunication

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