Coroner's Court of Western Australia

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

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


Delivered on : 7 October 2020

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

Suppression of the deceased’s name from publication and any evidence likely to lead to the child’s identification. The deceased is to be referred to as JM.

Summary : At the time of his death, JM was in the care of the Department of Communities and living in a remote community in the Kimberley. He was 10 weeks old.

On 1 July 2015 JM received his first immunisations. On 8 Jul 2015, he was unsettled and crying continuously in apparent pain. He appeared to have diarrhoea and he was given formula each time he opened his bowels.

JM was still unwell in the early morning of 9 July 2015. His foster father noticed he was not breathing properly and not responding, so he called the hospital and was advised that an ambulance would be sent and that he should drive JM to meet the ambulance part-way. JM’s foster parents had travelled about 3 km when they noticed that JM was not breathing. They then administered CPR as they travelled to meet the ambulance. Resuscitation attempts continued in the ambulance and upon arrival at Fitzroy Crossing Hospital, but JM could not be revived.

The Deputy State Coroner found that JM died from dehydration complicating diarrhoea (aetiology unknown) and death occurred by way of natural causes.

The Deputy State Coroner was satisfied that the care, supervision and treatment of JM was reasonable in the circumstances and that appropriate improvements had since been made to the care available in the community.

Catch Words : Department of Communities : Infant Placed in Care : Dehydration : Diarrhoea : Remote Community : Remote Area Nurses : Education : Natural Causes

Last updated: 16-Oct-2020

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