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TAShome2023-11-14

Coroner's Finding: de-identified OV

1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…

paediatricsemergency medicineadrenaline
WAhome2023-11-10

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

7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…

Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…

paediatricsrespiratory medicinemedicationsystemcodeine
VIChospital2023-11-08

Finding into death of K S

4y · Female·Drowning

A 4-year-old girl from an Afghan refugee family drowned in Lysterfield Lake after entering the water during a brief lapse of supervision. She was unable to swim and had not received water safety education. Despite immedi…

emergency medicineintensive caresystem
VIChospital2023-10-30

Finding into death of BCT

2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …

BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…

gastroenterologyradiologydiagnosticcommunicationceftriaxone
NSWhome2023-10-24

Inquest into the death of AW

2y · Female·effects of fire (smoke inhalation and thermal injury)

AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…

paediatricssocial worksystemdelay
VIChospital2023-10-20

Finding into death of Vanessa Li

0y · Female·subgaleal haematoma complicating an obstructed labour

Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…

obstetricsneonatologycommunicationdiagnosticoxytocin
TAShome2023-10-19

Coroner's Finding: de-identified FG

0y · Male·suffocation due to overlay by a sleeping adult

A 59-day-old premature infant died from suffocation due to overlay by a sleeping parent. The infant was placed on a mattress next to the parent's cot after refusing to settle in his own cot. Despite the parent's attempt …

paediatricsneonatologysystem
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient p…

psychiatrypaediatricssystemcommunicationfluoxetine
NSWhome2023-09-08

Inquest into the death of BW

31y · Male·hanging

B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…

paediatricspsychiatrycommunicationsystemalcohol
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
VIC2023-08-30

Finding into death of Baby A

0y · Female·Sudden infant death syndrome (SIDS) category 2

Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…

neonatologypaediatricssystemcommunicationmethadone
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol
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
NSWhome2023-08-15

Inquest into the death of LA

5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity

LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…

paediatricsintensive caredelaycommunicationmethadone
VIChome2023-07-27

Finding into death of Mr A

31y · Male·Hanging

Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …

psychiatrygeneral practicesystemcommunicationmethamphetamine
VIChospital2023-07-17

Finding into death of Sasha

12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …

A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …

paediatricsinfectious diseasescommunicationsystem
WAhospital2023-07-07

Inquest into the Death of Ashlee Jade REINDL

0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…

Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…

obstetricsmidwiferydiagnosticcommunicationoxytocin
SAhospital2023-06-30

Coroner's Finding: Vanin, Levi Shane

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

A 29-day-old neonate died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental …

obstetricsneonatologydinoprostone
WAhospital2023-06-29

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

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
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