Coroner's Court of Western Australia

Inquest into the Death of CNR (Subject to Suppression Order)

Inquest into the Death of CNR (Subject to Suppression Order)

Delivered on :28 August 2017

Delivered at : Perth

Finding of : Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

No report may be published of any part of the proceedings or of the evidence given at this inquest that could lead to the identification of the deceased or his family.

Summary : The deceased at the time of his death was in the care of the CEO of the Children and Community Services Act 2004.

The deceased was born into a loving family in a remote community. For his first nine years he was generally well but in February 2006 he was diagnosed with rheumatic fever.  He was prescribed monthly bicillin injections but was not always compliant.  In January 2010 he developed valvular heart disease and heart failure.

In October 2010 the deceased underwent mitral valve and aortic valve repair at Princess Margaret Hospital (PMH). Post operatively there was poor blood supply to the heart muscle which caused significant damage.  He developed biventricular congestive heart failure with ongoing aortic and mitral incompetence as well as tricuspid incompetence, with both right and left ventricles contracting poorly.

In January 2011 the deceased attended PMH cardiology outpatient clinic in significant heart failure. He was admitted to hospital on a number of occasions between August 2011 and March 2012 with heart failure related to poor compliance with medications.  For much of 2012 he was admitted to Kalgoorlie Regional Hospital.  In November 2012 he was transferred to Royal Perth Hospital where he underwent a radio frequency ablation procedure and the insertion of a pacemaker/defibrillator.  He was assessed as not suitable for cardiac transplantation because of his psycho-social capabilities, and as not suitable for a mechanical heart pump because of the condition of his heart.

The deceased was managed in PMH for the first part of 2013. He was in congestive heart failure and required large doses of diruetics to keep his weight gain and peripheral oedema under control.  He was taken into care by the Department of Child Protection and discharged to a foster family in early March 2013 so that he could be managed for his last few months through outpatient visits and admissions to PMH.

In April 2013 the deceased was admitted to PMH with acute kidney failure. From that time until his death he spent most of his time in hospital as his condition continued to deteriorate.  On 26 June 2013 he died in his sleep.

The Coroner found that the deceased’s death occurred by way of natural causes. The Coroner found that the care provided to the deceased was reasonable and appropriate.

Catch Words : Department of Child Protection : Rheumatic heart disease : Child in Care for Medical Management : Natural Causes

Last updated: 30-Apr-2019

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