Coroner's Court of Western Australia

Inquest into the Death of BC

Delivered on 17 December 2014 at Perth.

Finding of Deputy State Coroner Vicker.


Recommendation 1

I recommend continued resourcing of Aboriginal Ambulatory Care Coordination outreach program and its expansion to all regions in Western Australia. It is of critical importance to the provision of a future for aboriginal children.

Recommendation 2

I recommend the Department trial a practice requiring all mothers subject to the Department’s pre-birth planning processes to nominate a GP (or appropriate alternative) for the child for follow up purposes after birth.

Recommendation 3

I recommend Western Australian Country Health Service ensure the nominated GP both receives, understands and is supported for the implementation of follow up information and care.

Recommendation 4

I recommend Western Australian Country Health Service continue to progress the implementation of clinical information sharing systems to facilitate the sharing of patient information across the Kimberley, such as the Communicare system.

Recommendation 5

I recommend the Department and Western Australian Country Health Service work together to clarify the need to provide relevant health care information to the Department for children not "in care" but with families unlikely to understand the significance of complex medical information and needing assistance with complying with medical recommendations.

Suppression Order

That no report of the inquest or part of any proceedings which would identify or tend to identify the deceased be made in this matter and the deceased to be referred to as "BC".


The deceased was five months and eleven days of age at the time of his death. He was born a healthy full-term baby in Perth and after his birth he returned to the Kimberley with his mother. They were supported by the Department for Child Protection and Family Support but BC was not subject to a care and protection order.

The deceased became unwell in April 2010 and was taken to Wyndham Hospital, then transferred to Kununurra Hospital before being transferred to Princess Margaret Hospital in Perth. The deceased was discharged three weeks later on antibiotics. 

Although he had improved the cause of his illness remained undiagnosed. He was due for follow up review on 11 June 2010 at Kununurra Hospital.

The deceased’s mother asked the Department whether she could take the deceased to her family’s community and she was granted approval for a weekend visit. She was expected to return to her home on 14 June 2010.

There appeared to be no knowledge by the Department of the appointment for the deceased to be taken for review on 11 June 2010 at the Kununurra Hospital. The deceased and his mother did not return on 14 June 2010 as required.

On 17 June 2010 a disability support worker visited the community where the deceased and his mother were and observed the deceased whom he believed to be unwell. He reported the matter to a nurse at the community health clinic who was unable to access the Princess Margaret Hospital discharge information.

By the 21 June 2010 the disability support worker was still concerned about the deceased. He called the Department’s after hours Crisis Care Service and reported those concerns.

On 22 June 2010 staff from the Department drove to the community and found the deceased unresponsive.

The deceased was taken to medical facilities including being transferred by Royal Flying Doctor Service to Royal Darwin Hospital but he did not recover and died on 29 June 2010.

The inquest was held to determine exactly what happened to the deceased and whether any measure could be implemented to minimise the likelihood of a death arising from a similar set of circumstances.

The Coroner found that the deceased died on 29 June 2010 at Royal Darwin Hospital as a result of Acute Meningitis and death arose by way of Natural Causes. His death was probably preventable had there been intervention and the appropriate sharing of essential medical information.

The Coroner made five recommendations.

Catch Words

Acute Meningitis : Natural Causes : Sharing of medical information between agencies : Family Support rather than Care and Protection Orders.

Last updated: 20 July 2022

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