Inquest into the Death of David Kalunda FLYNN
Inquest into the Death of David Kalunda FLYNN
Delivered on :31 July 2025
Delivered at : Perth
Finding of : Coroner Hartley
Recommendations : N/A
Orders/Rules : N/A
Suppression Order : N/A
Summary : David Kalunda Flynn (David) was two years and eight months old when he died on 7 December 2021 following an elective circumcision procedure. The procedure was performed by General Practitioner Dr Raad Hassan (Dr Hassan) at Gosnells Medical Clinic (the Clinic). Dr Hassan had performed thousands of similar circumcision procedures over 40 years in general practice without any prior adverse outcome.
As was his usual practice for patients over 12 months of age, Dr Hassan administered morphine to sedate David for the procedure. The intended dose was 3mg, given by subcutaneous injection about 10 minutes before the procedure.
The circumcision procedure took place without complication and David slept on a bed in an adjoining treatment bay while his younger brother was circumcised after him. David was discharged from the Clinic less than an hour and a half after being administered morphine. CCTV footage from the Clinic shows a deeply sedated David being carried to the car by his mother.
David’s younger brother was unsettled from the time of his procedure onwards. He was in pain and bleeding more and more heavily from the site of the procedure. David’s mother was understandably focussed on her youngest son in the hours after returning home from the Clinic.
When she touched David’s legs in the early evening they were cold, David’s mother immediately realised something was wrong. It was quickly established that he wasn’t breathing. An ambulance was called and CPR commenced. Despite the best efforts of family, ambulance officers and medical staff at Armadale Hospital, David could not be revived. His younger brother was rushed to Perth Children’s Hospital for emergency surgery to control bleeding from his frenular artery.
Through expert toxicological evidence, which was refined in conjunction with a better understanding of the factual circumstances in the hours before David’s death, it was established that the cause of death was opioid toxicity. It is clear that any overdose of morphine by Dr Hassan was inadvertent.
An experienced paediatric anaesthetist and similarly well credentialled paediatric surgeon assisted the Court with expert evidence in relation to the appropriateness of performing a circumcision under sedation in a general practice setting. While both experts expressed their preference for the procedure to occur under general anaesthetic in a hospital or day clinic, they understood that circumcisions have occurred for thousands of years for a range of reasons in various settings, most often without incident.
The requirements set out in the Australian and New Zealand College of Anaesthetists’ PG09(G) Guideline on procedural sedation 2023, which is endorsed by the Royal Australian College of General Practitioners, are the measure against which Dr Hassan’s clinical decision making in relation to David were measure. He fell short on a number of counts, most significantly, by conducting no formal peri or post-operative monitoring and failing to comply with accepted discharge criteria.
Issues were also identified around the use of morphine as a sedating agent, the chosen mode of administration, the concentration of the solution and the type of syringe used by Dr Hassan.
Ultimately it was concluded that, had David been monitored after the procedure and only discharged from the Clinic once he had returned to baseline observations, his death would very likely have been preventable.
This matter was referred to the Australian Health Practitioner Regulation Agency for consideration of Dr Hassan’s conduct.
Catch Words : Circumcision procedures : Procedural administration in general practice setting; Administration of morphine : Record Keeping for Schedule 8 Medication : Administering anaesthesia for children : Misadventure
Last updated: 19 August 2025