Inquest into the Death of Child MML
Delivered on: 23 February 2026
Delivered at: Perth
Finding of: Coroner Tyler
Recommendations: No
Orders/Rules: No
Suppression Order:
Suppression of:
- The deceased’s name from publication and any evidence likely to lead to the child’s identification.
The deceased is to be referred to as Child MML.
Summary:
On 24 September 2021, an 11 year old Aboriginal child, Child MML, died in Perth as a result of bronchopneumonia and small bowel necrosis with perforation, in a boy with multicystic encephalopathy and organised subdural membrane, on long term enteral feeding, with terminal palliative care. Child MML was in the care of the CEO of the Department of Communities (the Department) at the time of his death, so his death was a reportable death and a coronial inquest was mandatory.
When Child MML was eight months old, Child MML was taken to Princess Margaret Hospital by his paternal grandmother. Medical tests revealed that Child MML had suffered a traumatic brain injury and various other injuries to his body.
The circumstances in which Child MML suffered these injuries are not known. Child MML’s mother, and then step-father were unable to give an explanation as to how Child MML had been injured, other than a suggestion that Child MML’s step-father had been playing “too hard” with him.
An investigation conducted by the Department of Communities (the Department) found that Child MML suffered substantiated physical abuse and neglect while in the care of his mother and then step-father. The Department concluded that his then step-father had caused significant harm to Child MML in relation to physical abuse, and his mother had caused significant harm to Child MML in relation to neglect.
No person was ever criminally convicted of inflicting the abusive head trauma upon Child MML. Child MML’s mother, and then step-father, were convicted of engaging in reckless or deliberate conduct that may result in a child suffering harm as a result of neglect, due to their failure to ensure Child MML received timely medical care for his injuries. They were each sentenced to imprisonment.
As a result of these events, Child MML was placed into the protection and care of the Department of Communities (the Department) on 22 December 2010, at which time he was still in hospital as a result of his injuries. He remained under the protection and care of the Department until his death.
Due to the injuries Child MML suffered, he had profound lifelong physical and cognitive disabilities, requiring high-level, 24 hour care. The Department placed Child MML into the care of his paternal grandmother, and he remained in her care for the rest of his life, until he died on 24 September 2021 at the age of 11 years old.
At the conclusion of the coronial inquest, the Coroner was satisfied that Child MML died as a natural consequence of the deterioration of his respiratory function and pneumonia, and small bowel necrosis and bowel perforation. These conditions occurred in the setting of a catastrophic traumatic brain injury, and severe neurological impairment, inflicted upon Child MML when he was an infant.
The Coroner noted that there was a degree of uncertainty not only about how Child MML’s abusive head trauma occurred, but also its relevance to the death. In light of that uncertainty, the Coroner made an open finding as to the manner of death.
The Coroner found that the care provided to Child MML by his paternal grandmother while he was in the care of the Department was exceptional. The Coroner also acknowledged the very high standard of the care provided to Child MML by workers from the Department, and from the Child and Adolescent Health Service. Save for one issue regarding communication between the Department, and the Child and Adolescent Health Service in relation to planning for Child MML’s end of life care, the Coroner found that the quality of the supervision, treatment and care provided to Child MML while he was in the care of the Department was exemplary.
Catch Words: Mandatory Inquest – Care, Supervision and Treatment While in Care: Department of Communities.
Last updated: 1 April 2026