Coroner's Court of Western Australia

Inquest into the Death of KPLW (Subject To Suppression Order)

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

Delivered on : 30 January 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The deceased’s name and any evidence likely to lead to the deceased’s identification are suppressed from publication. The deceased is referred to as KPLW.

Summary : The deceased at the time of death was a child in the care of the Department for Child Protection and Family Support.  The protection and care order was in place until the deceased turned 18 years old.  The order was supported by the deceased’s biological mother and maternal grandmother.  The deceased was placed in foster carers as a baby and the deceased remained with her foster carers until she died on 29 March 2013 at the age of 7 years.

The focus of the inquest was primarily on the care and supervision provided to the deceased prior to death by the foster carers arranged by the Department.

The deceased was healthy at birth and quickly discharged home from hospital to live with her biological parents and older sibling. When the deceased was six weeks old the deceased was taken by family to the Peel Health Campus and then transferred to Princess Margaret Hospital where extensive medical tests revealed an acquired brain injury and various other injuries to the deceased’s body.  The deceased’s family were unable to give an explanation as to how the deceased had been injured, although the nature of the injuries suggested the deceased had been violently shaken.  An investigation failed to identify the perpetrator, however, the Department’s investigation raised concerns that the deceased’s parent may have inadvertently caused harm to the deceased through rough handling, and at the very least they had not been sufficiently protective of the deceased.

Due to the deceased’s profound physical and cognitive disabilities the deceased required high level 24-hour care. In June 2006 the deceased was placed with foster carers who were experienced in providing care to children with special needs.  The deceased remained with these foster carers until her death.

In March 2013 the deceased had been unwell with a respiratory illness and had received medical treatment. On 29 March 2013 the deceased’s foster mother woke up and observed the deceased’s breathing was laboured.  She immediately checked the deceased’s blood oxygen levels and temperature and noted that both were low.  The deceased was driven to the Northam Regional Hospital and the deceased’s foster mother noticed that the deceased was crying and struggling to breathe during the journey.  A few minutes before reaching the hospital the deceased gave a cry and stopped breathing altogether.  The deceased’s foster mother immediately delivered a few blows to the deceased’s back in an attempt to start her breathing again but was not successful.  Upon arriving at the hospital staff immediately attended and began to give the deceased CPR in an attempt to resuscitate her.  Two doctors attended and assist in resuscitation efforts and despite all efforts the deceased was certified life extinct.

The Coroner concluded the deceased died in circumstances consistent with respiratory failure and acute pancreatitis win a young girl with cerebral palsy, seizure disorder and chronic respiratory problems.

The Coroner noted the deceased’s foster carers were committed to providing a safe, supportive and loving environment for the deceased throughout the deceased’s relatively short life. The Coroner was satisfied the deceased’s care and supervision was appropriate and of a very high standard.

Catch Words : Protection and Care : Foster Placement : Disability : Natural Causes


Last updated: 30-Apr-2019

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