Coroner's Court of Western Australia

Inquest into the Death of Child SH

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

Delivered on : 21 November 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

Suppression from publication of the deceased’s name and any evidence likely to lead to the deceased’s identification. The deceased is to be referred to as “Child SH”.

Summary: At the time of his death, the deceased (Child SH) was in the care of the Director General of the Department of Communities (DG). Child SH was 5 years old and died at Perth Children’s Hospital on 1 September 2018 from aspiration pneumonia.

Child SH was born with several serious congenital conditions, including undifferentiated congenital myopathy (a form of muscle weakness). As a result of these conditions, Child SH had very complex needs and was totally reliant on a carer for all activities of daily living. Child SH was unable to walk and used a wheelchair and had an unsafe swallow, meaning he was tube fed. Child SH had swallowing issues which led to numerous hospital admissions for aspiration pneumonia and respiratory tract infections. During these admission, Child SH usually required respiratory support by way of an airflow mask (BiPAP mask).

On 28 August 2018, the DG approved a care plan whereby, should Child SH’s condition deteriorate, Child SH would be treated palliatively and not resuscitated. On 28 August 2018, Child SH became febrile and was treated with oral antibiotics. On 29 August 2018, Child SH became distressed and anxious because of Child SH breathing difficulties and the dosage of morphine and midazolam infusions were increased. During 30 August 2018, Child SH appeared to be distressed whilst wearing the BiPAP mask and the skin on Child SH face broke down in several areas. As a result, the mask was removed and a high-flow oxygen mask was placed near Child SH head instead.

Child SH’s condition continued to deteriorate and antibiotics were ceased on 31 August 2018. Child SH died on 1 September 2018.

The Department of Communities properly conceded that Child SH’s mother should have been provided with more intensive support in March 2018. The Coroner observed that the Department had made a number of improvements to its service delivery aimed at enhancing its child safety response.

Catch Words : Death in Care : Resuscitation Plan : Family Support : Natural Causes

Last updated: 9-Jan-2020

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