Coroner's Court of Western Australia

Inquest into the Death of Christopher Ling Tao

Delivered on 13 February 2015 at Perth.

Finding of Deputy State Coroner Vicker.


The deceased was 2 year 9 month old toddler at the time of his death. He was bright, alert, healthy and developmentally normal.

On the evening of 2 September 2010 the deceased appeared quieter than usual, he developed a high temperature, his parents initially treated him with fluids and Panadol assuming he was developing a cold.

On 4 September 2010 due to his continuing unwellness his parents presented with him to Princess Margaret Hospital Emergency Department where he was assessed and then discharged home.

On 6 September 2010 his parents took the deceased to the family GP who suspected the rash which the deceased had developed may relate to allergies.

On 7 September the deceased remained unwell and returned to Princess Margaret Hospital where he was assessed and discharged home with a diagnosis of a viral illness. The deceased had an elevated temperature for five days, dry cracked lips, inflamed eyes, a rash and cervical lymphadenitis.

The deceased was reviewed by the family GP on 8 September 2010 and his parents were assured he would improve.

The deceased remained unwell and late on 9 September 2010 the deceased’s father found him unresponsive in bed. Resuscitation was commenced and an ambulance called.

The deceased was transferred to Princess Margaret Hospital Emergency Department but could not be resuscitated and died early on 10 September 2010.

The issues which were explored at the inquest hearing were the assessments provided to the deceased at each of his presentations at Princess Margaret Hospital and his GP and the cause of the deceased’s myocarditis.

The Coroner was satisfied the deceased was diagnosable with Kawasaki Disease on his presentation on 7 September 2010. It was not clear myocarditis was diagnosable on 7 September 2010. Kawasaki Disease is a clinical diagnosis only and is a rare disease. Myocarditis is an even rarer outcome of Kawasaki Disease.

The Coroner accepted evidence from experts who confirmed prevalent community illnesses do play a part in emergency department diagnoses and value judgments around management of differential diagnoses may be conflicted.

However, a high degree of suspicion should be maintained over a diagnosis of Kawasaki Disease, especially where five diagnostic signs were present, due to its serious coronary outcomes.

The Coroner agreed admission and monitoring would have been a preferable option in the treatment of the deceased on his presentation to the hospital on 7 September 2010, but it was not certain the outcome would have changed.

The Coroner found the deceased died as a result of myocarditis induced by Kawasaki Disease and death arose by way of Natural Causes.

Catch Words

Kawasaki Disease : Myocarditis : Clinical Diagnosis : Natural Causes.

Last updated: 16 August 2022

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