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NSWchildcare2026-05-06

Inquest into the death of Arianna Maragol

1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…

Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…

paediatricsemergency medicinesystemcommunicationibuprofen
VIChospital2026-05-04

Finding into death of Baby E

3y · Female·COMPLICATIONS FROM SEVERE CEREBRAL PALSY

Baby E, a 3-year-old with severe cerebral palsy, spastic quadriplegia, bulbar dysfunction and upper airway obstruction, died from complications of her severe cerebral palsy. She presented with seizures, dark green sputum…

intensive carepaediatrics
NThome2026-04-30

Inquest into the death of Baby S, Baby K, Baby B - (Co Sleeping)

Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …

Three Aboriginal infants died in unsafe co-sleeping environments in the Northern Territory. Baby K (3 months), Baby B (2 months), and Baby S (5 weeks) all died from sudden unexpected death in infancy (SUDI) associated wi…

paediatricsmidwiferycommunicationsystemalcohol
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
WAhospital2026-03-27

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
VICcommunity2026-03-23

Finding into death of PCH

14y · Female·Drowning in a person with epilepsy

PCH, a 14-year-old girl in out-of-home care with a history of epilepsy, drowned in a river while washing her hair during a family camping trip. She had experienced increased seizure frequency in October-November 2024, pr…

paediatricsneurologylamotrigine
NThome2026-03-20

Inquest into the death of Ralph Donald

35y · Male·self-inflicted gunshot wound to the head

Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…

psychiatryaddiction medicinesystemcommunication
VICcommunity2026-03-18

Finding into death of NJC

17y · Male·drowning

NJC, aged 17, drowned in Lake Nagambie while subject to a Care by Secretary Order. He was in stable kinship care with his sister and receiving appropriate support from Child Protection and Anglicare. At a family wedding …

forensic medicineaddiction medicinealcohol
NSWhospital2026-03-17

Inquest into the death of Serena Lee

1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…

Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…

neonatologymidwiferydiagnosticsystem
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
WAhospital2026-02-23

Inquest into the Death of Child MML

11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…

neurologypaediatricscommunicationsystem
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
WAhome2025-12-22

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

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

A 14-year-old Aboriginal boy with newly diagnosed epilepsy died unexpectedly on 24 August 2023 after an unwitnessed seizure while sleeping at his residential care home. He had been diagnosed with epilepsy in June 2023 fo…

paediatricsneurologycommunicationsystemsodium valproate
WA2025-12-17

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

14y · Female·ligature compression of the neck (hanging); suicide

A 14-year-old girl in state care (Child RK) died by suicide on 20 April 2022. She had complex presentations stemming from early childhood trauma, including attachment difficulties, emotional dysregulation, self-harm, sui…

psychiatrypsychologycommunicationsystemmelatonin
WAhospital2025-11-05

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

0y · Male·Streptococcus pyogenes and parechovirus infection

An eight-month-old boy in state care died from Streptococcus pyogenes and parechovirus infection. He presented to hospital twice before death with fever and ear infection symptoms. On first presentation (2 September), he…

emergency medicinegeneral practiceparacetamol
VIChome2025-10-28

Finding into death of HCG

39y · Female·Unascertained

A 39-year-old woman experiencing intimate partner violence was assaulted by her partner on 31 January 2021 and died approximately 5 hours later. The assault caused significant blood loss; however, the medical cause of de…

forensic medicinepaediatricssystemcommunicationmethamphetamine
NT2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
VIChospital2025-09-25

Finding into death of Dio Miranda Katiana Kemp

3y · Female·Streptococcus pyogenes septicaemia

A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…

emergency medicinepaediatricsdiagnosticcommunication
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
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