545 results
0y · Female·Undetermined - coroner unable to determine exact cause; unsafe sleeping environm…
A 5-month-old infant died suddenly in a co-sleeping environment with adults and a toddler in a queen-sized bed with adult bedding. Autopsy revealed no definitive cause but identified significant risk factors: unsafe slee…
0y · Male·Pneumonia in the setting of malnutrition
Baby A, born at home without medical assistance, died at 19 days old from pneumonia complicated by severe malnutrition and dehydration. He weighed 2.87kg at autopsy, far below his reported 4kg birth weight. He had diffic…
43y · Female·Neck compression
TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disor…
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…
15y · Male·ligature compression of the neck (hanging)
Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…
1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown c…
A 22-month-old boy died from global cerebral ischaemic injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine exposure. He had multiple healing traumatic injuries (rib fra…
5y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
A 5-year-old boy who could not swim drowned in a public aquatic centre after crossing from a shallow ramp area into a 1.2-metre deep main pool, unobserved by his parents. He was underwater for 90 seconds before being ret…
9y · Female·suicide by hanging
A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and placed with non-Aboriginal carers despite legislation requiring Aboriginal …
0y · Female·Neonatal death in the setting of meconium aspiration
A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive asse…
3y · Female·complications of Influenza B viral infection
Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…
0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…
varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…
Coroner's joint inquest into deaths of seven children (six infants and one child aged 16 years) between 2014 and 2018 in Tasmania. All families had history of Child Safety Services (CSS) involvement. Coroner found no dir…
0y · Unknown·sepsis leading to multiple organ failure syndrome
A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …
15y · Unknown·acute respiratory distress syndrome resulting from multi-organ failure as a cons…
Child A, aged 15, died from acute respiratory distress syndrome resulting from multi-organ failure due to disseminated tuberculosis. He presented to hospital with very advanced post-primary pulmonary tuberculosis requiri…
1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction
NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…
8y · Male·acute exacerbation of chronic asthma
An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…
15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…
HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension. He had dysfunctional eating patterns, …
3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea
A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complic…
12y · Female·Undetermined (asphyxiation or choking)
Tiahleigh Palmer, age 12, was murdered on 29 October 2015 by her foster carer Richard Thorburn, who asphyxiated or choked her. The coroner identified critical systemic failures including: inadequate permanency planning b…
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