Coroner's Court of Western Australia

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

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

Delivered on :11 March 2016

Delivered at : Perth

Finding of : Coroner King

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

The identity of the deceased, the deceased’s parents, the deceased’s foster carers and the foster carers’ family, including the 18 year old boarder, and any detail that could lead to identifying any of those persons, not be published.

Summary : The deceased was two years old when she died suddenly in her cot on 31 December 2010.  At the time the deceased was in the care of the Department for Child Protection and was placed with foster carers. She was a healthy, happy and alert child with strong attachments to her foster carers and her foster siblings.  She also attended contact visits with her parents and her biological siblings, so she maintained a bond with them.

The deceased’s health was generally good, but she had experienced three minor febrile seizures, with the last one being in October 2010.

On 30 December 2010 the deceased had been in the backyard pool with the family and nothing unusual had occurred that afternoon.  After dinner the deceased had a slight temperature so was given a child dosage of paracetamol and placed in her cot.  The deceased shared a room with a boarder who went to bed around 10.00 pm that night. 

At approximately 2.00 am on 31 December 2010 the deceased’s foster carer checked the deceased and felt that her temperature had come down.  In the early hours of the morning the boarder woke briefly and heard the deceased talking softly to herself in her sleep, which she often did.  At 7.30 am the boarder awoke briefly.  The deceased appeared to be sleeping face down.  At about 8.15 am the boarder got up and saw that the deceased was facing straight down with her arms straight by her side.  She was pale and had blue patches all over her body.

The foster carer administered cardiopulmonary resuscitation until St John Ambulance officers arrived but the deceased could not be revived.

A forensic pathologist found no evidence of injury or natural disease to account for death.  Extensive further investigations were undertaken with the assistance of a paediatric and neonatal pathologist and a neuropathologist, but the forensic pathologist was unable to ascertain a cause of death.  Genetic testing did not show a relevant abnormality.

The Coroner found that the deceased died from an unascertained cause and that death occurred by way of natural causes.

The Coroner found that the supervision, treatment and care of the deceased was reasonable and appropriate

Catch Words : Department of Child Protection : Child In Care : Foster Carers : Seizures : Natural Causes: SUDI

Last updated: 3-May-2024

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