Coroner's Court of Western Australia

Inquest into the Death of Dylan James RILEY

Inquest into the Death of Dylan James RILEY

Delivered on 23 September 2019

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was 16 years old at the time of his death and was in the care of Fiona Stanley Hospital.

The deceased was diagnosed with paediatric nephrotic syndrome when he was six years old, and received medical treatment for his condition. It was considered that he might outgrow the condition as he moved towards adulthood, as a majority of children with this type of nephrotic syndrome do.

The deceased had frequent relapses over the years, but responded well to steroid treatment each time. In January 2015 after a change in medication the deceased remained in remission until early July 2015, when his symptoms began to re-emerge. This did not generate concern, as the medication the deceased was receiving usually wears off after about 6 to 12 months and he was due for another dose. The deceased was started on steroid treatment and a plan was put in place to give him another dose of his medication when had come back into remission.

On 29 and 30 July 2015 the deceased became increasingly unwell with significant fluid retention and increasing shortness of breath. The deceased was taken to hospital by his parents on 31 July 2015. The deceased was noted to be short of breath and was hypoxic, tachycardic and hypotensive. The deceased was given fluids and a prophylactic dose of an anticoagulant medication, Clexane, as he was known to be at increased risk of thrombosis due to his condition. The deceased was then transferred to Fiona Stanley Hospital for further treatment.

Medical staff felt that the deceased’s symptoms were related to acute pulmonary oedema although a pulmonary embolism remained part of the differential diagnosis. Treatment for acute pulmonary oedema was given and the deceased was transferred to the ICU.

At about 7.00 am on 1 August 2015 the deceased’s oxygen saturations dropped and he became increasingly unwell and confused. Just before 10.00 am a bedside echocardiogram showed right heart failure and a diagnosis of probable massive pulmonary embolus was made. A cardiothoracic surgeon was consulted who advised the deceased was not a candidate for surgical removal of emboli and suggested thrombolysis instead. The deceased was given a thrombolytic agent but his condition did not improve and he went into cardiac arrest and could not be resuscitated.

Catch Words : Pulmonary embolism : Nephrotic Syndrome : Natural Causes.

Last updated: 15-Oct-2019

[ back to top ]