Coroner's Court of Western Australia

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

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


Delivered on : 23 September 2020

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : Yes

Recommendation 1

I recommend that the Western Australian Government undertakes a regulatory impact review and if appropriate, introduces: 

  • an amendment to the Children and Community Services Act 2004 (WA) to include a duty to report any injuries in a non-ambulant child, in similar terms to the reporting structure for the reporting of sexual abuse of children requirements contained in Division 9A of Part 4 of the Children and Community Services Act 2004 (WA); and 
  • an extension to the current mandatory training program jointly provided by the Department of Communities and the Department of Health – Child and Adolescent Health Services regarding the reporting of sexual abuse of children requirement contained in Division 9A of Part 4 of the Children and Community Services Act 2004 (WA) to include education on the duty to report any injuries in a non-ambulant child. 

Orders/Rules : N/A

Suppression Order : Yes

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

Summary : At the time of death PT was in the care of the Department of Communities and had been placed into the care of foster carers. PT was profoundly disabled and required a high degree of care. She remained a non-verbal quadriplegic with cerebral palsy, she suffered from seizure disorder, she was visually impaired and she needed to be fed by means of a percutaneous endoscopic gastrostomy tube. She was five years old. 

On 15 February 2011 when PT was five weeks of age she was taken to be reviewed by the Community Health Nurse. PT was observed by the Community Health Nurse to have bruises on the left side of her cheeks and chin and a small scratch on her nose and forehead. It was recommended PT be taken to see a GP. The GP knew PT’s mother and grandmother. The GP ordered blood and urine tests were ordered to exclude infection or other significant illness. On 18 February 2011 results revealed raised platelets and at the material time the GP did not apprehend that platelets may be raised as a response to trauma. 

On 24 February 2011 PT was taken by her mother to the Community Health Nurse and it was observed that PT had bruising on the left side of her cheek and right upper forehead. As a consequence of the mother’s defensive response the Community Health Nurse referred the matter of PT’s injuries to the DCP, by telephone contact. This was the first time PT came to the attention of the DCP. On the same day a home visit was conducted. Arrangements were made for PT to be taken to see the GP the following day, however, the GP did not understand this consult to be an examination of PT to be on behalf of DCP. At the request of PT’s mother the GP wrote an open letter which supported her parenting and to assist her with her concerns that she was wrongly accused by DP of harming her baby. This letter was then provided by PT’s mother to DCP. 

Initially on 1 March 2011 PT had been taken to the Regional Hospital Emergency Department by her mother and grandmother expressing concerns that PT was not feeding. Bruising was noted but medical staff did not believe the bruising was due to abuse. Later that same day PT was taken to see another GP with lethargy and poor oral intake. PT was pale, had bruising to her face, her fontanel was bulging, her left eye was deviated and her left arm and leg were jerking. PT was immediately transferred to the Regional Hospital by ambulance and it was suspected she had an intracranial bleed. A further transfer to PMH was arranged and PT was admitted to the Paediatric Intensive Care Unit and placed on full life support. 

On 9 March 2011 DCP applied for a Protection Order on the grounds that PT’s injuries were serious and the perpetrator was unknown. A Protection Order was granted on 13 June 2011 with an extension subsequently granted on 5 May 2014. On 13 April 2011 PT was three months old when she was discharged from PMH to live with foster carers appointed by DCP. The foster carers provided a warm and loving environment and assiduously took care of PT’s medical needs. 

The State Coroner highlighted the risks of injury to non-ambulant children leading to a consideration of how events in similar circumstances could be prevented in the future. The State Coroner made a recommendation with the aim of mitigating the risk of a missed opportunity to intervene, because serious injuries may be preceded by injuries of lesser seriousness that should be regarded as sentinel injuries in a non-ambulant child. 

The State Coroner found PT died on 27 January 2016 at St John of God Hospital, Midland, as a result of aspiration of vomit, with microscopic early pneumonia in a child with a history of cerebral palsy and epilepsy. 

Catch Words : Department of Child Protection : Mandated Reporting of Injuries : High Risk Infant Policy : Natural Causes

Last updated: 12-Oct-2020

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