The Western Australian Coroner’s Report, in conjunction with the HDWA Public Safety Surveillance Unit publish an annual report “From death we learn“. This makes for tragic, but meaningful reading, and there are cases relevant to paediatrics. In the current 2016 edition (the past nine years of editions can be found here), is a case of Kawasaki Disease resulting in death by myocarditis, a button battery causing an aorto-oesophageal fistula, and a collection of unfortunate neonatal deaths. The PSSU has made clear the learning points in each case.

There may be similar reports available elsewhere. The Cororner’s Court of Victoria is searchable using keywords and includes the recent experience of unpasteurised milk causing fatal HUS in a child, or you can read their Clinical Communiques. New South Wales reports coronial recommendations via their Department of Justice website. Queensland publishes governmental responses to coronial recommendations also, however paediatric content is not as easily discoverable  – you need to do a manual search. New Zealand also publishes recommendations on their Coronial Services website – again you need to manually search for child health related recommendations.