Coroner's Court of Western Australia

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

Inquest into the Death of SM

Delivered on :14 May 2019

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

That the name of the deceased and any identifying information be suppressed from publication. The deceased is to be referred to as “SM”

Summary : The deceased at the time of death was in the care of the CEO of the Department of Communities, then called the Department of Child Protection and Family Support. The deceased had profound disabilities and was only able to smile and vocalise loud sounds, but not words. The deceased was fed by a percutaneous endoscopic gastrostomy (PEG) tube and required 24/7 care. The deceased was cared for at Lady Lawley Cottage until suitable carers could be found.

The deceased was placed with a carer family on the 28 April 2014. Multiple agencies were involved in the provision of care to the deceased and it was noted the deceased’s health had been deteriorating since the placement into the family care by way of increased seizure activity and respiratory infection, however, the deceased increased in weight and appeared to enjoy being part of a family unit.

The deceased was admitted on 1 August 2014 to Joondalup Health Campus with excessive amounts of seizures. These seizures had increased since the deceased had returned home from a previous hospital admission, 27 July to 31 July 2014. The deceased was transferred to Princess Margaret Hospital but, unfortunately, the deceased’s condition deteriorated and sometime before 6.20 am on 2 August 2014 the deceased became unresponsive. The deceased was resuscitated and placed in paediatric ICU while unsuccessful attempts were made to locate his biological mother. The deceased’s life support was removed and he died at 6.15 pm on 2 August 2014.

The Deputy State Coroner concluded the overall view of the deceased’s supervision, treatment and care were appropriate while in the care of the Department of Communities.

Catch Words : Caring for Children with Disabilities : Continuous Monitoring in a paediatric hospital setting : Natural Causes.

Last updated: 30-May-2019

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