Coroner's Court of Western Australia

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

Inquest into the Death of Child LDW

Delivered on : 16 April 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The deceased’s name is suppressed from publication.  The deceased should be referred to as Child LDW in any external publication and no information should be published that might lead to the identification of the deceased.

Summary : At the time of her death Child LDW was in the care of the Department of Communities and living with her step-father and her three siblings.  On 14 August 2017 Child LDW was found unresponsive and lifeless in her bed by her step-father.  He drove to hospital where her death was confirmed.  She was 3 years old.

Immediately before death Child LDW a “person held in care” under the Coroners Act 1996 because she was placed under the care of the CEO of the Department of Communities, pursuant to the Children and Community Services Act 2004

Child LDW was taken by the Department from her mother’s care for safety reasons and was temporarily living with her step-father and siblings.  Planning was undertaken to return her to her mother’s care at the time of her death.

Child LDW was sighted by her case manager on 20 January 2017, 3 March 2017 and 17 March 2017 for her Quarterly Case Reports and there were no concerns recorded while she was in her step-father’s care.  Her step-father appeared to be doing the best that he could to care for the children by himself with little support or respite.

In May 2017 the deceased’s step-father had broken his wrist.  He also had a pre-existing back injury that was causing him chronic pain.  He was prescribed opioid pain relief medications in the form of tramadol capsules to assist with pain management for his wrist and back injury.

On the Saturday of the weekend before her death, the deceased and her siblings were collected by their maternal grandmother and taken to see their mother for a home visit.  Child LDW’s step-father asked if the children could stay with their grandmother for a sleepover.  She declined as she was concerned they would get into trouble if the Department found out and they might stop allowing the children to visit.

After their contact visit the children returned to their home arriving in the early hours of Sunday morning.  The deceased and one of her siblings appeared to be coming down with a cold.  On the Sunday morning the deceased had tea and toast and slept in the lounge on and off throughout the day in front of the heater.  The deceased ate her dinner and then lay on a mattress in the lounge room.  At about 7.00 pm the deceased vomited a small amount and she looked unwell, like she had the flu.  She went back to sleep, but at about 8.30 pm the deceased vomited again.   The deceased then got up and was noticed to be a staggering a little.  She then went to the toilet and then to bed.

The deceased and one of her siblings still appeared to be sick the next morning so it was decided to keep them home for the day and they were left in bed.  At 2.00 pm one of the children got up to watch television and Child LDW’s step-father went to check on the deceased.  She was wet and floppy when picked up.  The deceased’s step-father immediately took her to the hospital, where her death was confirmed shortly after her arrival.

The death was not initially treated as suspicious by the police.  However, after the cause of death was determined to be tramadol toxicity, the death prompted the WA Police Homicide Squad to launch a full criminal investigation into the circumstances of the deceased’s death.  The deceased’s step-father was interviewed as a suspect as part of that investigation.  At the end of the investigation the police could not exclude the possibility that the deceased had found the tramadol and taken it herself.

The Deputy State Coroner noted that after a review by the Department it had implemented a range of practice improvements since the deceased’s death.

The Deputy State Coroner concluded the supervision and care by the Department was below the appropriate standard expected.  There were missed red flags that should have prompted a more proactive approach to assessing the step-father’s ongoing suitability to care for the children.  As a result, there was a missed opportunity to intervene and possibly prevent the death.

Catch Words : Department of Community : Supervision, Treatment and Care : Open Finding

Last updated: 23-Sep-2021

[ back to top ]