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NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…

emergency medicinesurgerydiagnosticcommunication
NSWhospital2019-12-13

Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…

general practiceemergency medicinediagnosticcommunication
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…

emergency medicinepaediatricsdiagnosticcommunication
NSWhome2017-12-01

Inquest into the death of AF

3y · Female·peritonitis caused by small bowel perforation due to blunt force trauma

A 3-year-old girl died from peritonitis caused by small bowel perforation. Expert evidence established the perforation resulted from blunt force trauma, not natural disease or accidental mechanisms. The manner of injury …

paediatric surgerypaediatricscommunicationsystemparacetamol
NSWhospital2016-12-21

Inquest into the death Kyran DAY

<1y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…

paediatricsemergency medicinediagnosticcommunication
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

8y · Male·Septic shock consequent on burst appendix with peritonitis

Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…

emergency medicinegeneral practicediagnosticcommunicationampicillin

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