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NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication
VIChospital2023-05-29

Finding into death of Kaleb Baylis-Clarke

0y · Male·Head injury in the setting of chronic subdural haemorrhage

Kaleb Baylis-Clarke, a 17-week-old infant, presented to hospital on 14 January 2016 with a head lump, vomiting, raised fontanelle and reduced milk intake. Cranial ultrasound showed fluid in subdural spaces. MRI on 15 Jan…

paediatricsneurosurgerysystem
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
SA2023-04-06

Coroner's Finding: Chilcott, Zhane Andrew Keith

13y · Male·Hanging

Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…

paediatricsgeneral practicesystemcommunication
TAShospital2023-04-03

Coroner's Finding: RS - de-identified

1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…

A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…

emergency medicinepaediatricsdiagnosticsystem
NThospital2023-03-31

Inquest into the death of Kumanjayi Holmes

15y · Female·complications of Batten disease (CLN3)

Damilia Kelly Holmes, a 15-year-old Aboriginal girl, died from complications of Batten disease (CLN3) while in palliative care. She was in out-of-home care under the Territory Families and Housing (TFHC) and was loved an…

palliative carepaediatrics
VIChospital2023-03-31

Finding into death of Callie Griffiths-I'Anson

2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…

Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…

paediatric surgeryanaesthesiacommunicationsystemmidazolam
VIChome2023-02-27

Finding into death of Baby A

0y · Unknown·Unascertained

A six-week-old premature infant died of unascertained causes while co-sleeping with parents on an adult bed with soft pillows and loose bedding. Baby A had multiple SIDS risk factors including prematurity, low birthweigh…

paediatricspathologyMDMA
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …

emergency medicinepaediatricsdiagnosticcommunication
QLDhospital2023-02-13

Hunter- Non-inquest findings

8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…

An eight-year-old boy with autism spectrum disorder (level 1) died from ischaemic bowel due to strangulated small bowel obstruction from a rare congenital band adhesion. He presented to a regional hospital with abdominal…

surgerypaediatricsdiagnosticcommunicationondansetron
VIChome2023-01-25

Finding into death of Master T

1y · Male·Chronic Bronchial Asthma

Master T, a 17-month-old boy with chronic asthma, died from status asthmaticus on 25 November 2019. He had experienced recurrent wheezing episodes requiring multiple hospital admissions in September-October 2019. Medical…

paediatricsemergency medicinecommunicationsystemsalbutamol
WAhome2023-01-09

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

3y · Male·Pneumonia and respiratory failure in association with metachromatic leukodystrop…

Child F, aged 3 years, died of pneumonia and respiratory failure complicating metachromatic leukodystrophy (MLD), a rare neurodegenerative genetic disorder. He had previously suffered severe non-accidental injuries inclu…

paediatricsneurologymorphine
NTcommunity2023

Inquest into the death of Toddler R

3y · Male·Disseminated Staphylococcus aureus infection

A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…

general practicepaediatricsdiagnosticdelayparacetamol
WAhome2022-12-08

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

3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…

A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…

endocrinologypaediatricssystemdelayhydrocortisone
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…

paediatricsemergency medicinecommunicationsystemadrenaline
VIChospital2022-11-18

Finding into death of G K

3y · Unknown·High grade pontine glioma

A three-year-old child in foster care died from high-grade pontine glioma, an aggressive brain tumour. The child had presented with severe developmental delay, behavioural problems, and global developmental concerns attr…

paediatricsneurosurgery
NSWcommunity2022-10-21

Inquest into the death of Riley Christopher Shortland

8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorway after escaping from a vehicle during respite care. He removed his se…

occupational therapypsychologydiagnosticcommunication
NSWout-of-home care2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
NSWcommunity2022-10-21

Inquest into the death of Rachel Martin

28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited …

social workpaediatricscommunicationsystem
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