Coroner's Court of Western Australia

Inquest into the Death of TS (Subject to a Suppression Order)

Inquest into the death of TS (Subject to a Suppression Order)

Delivered on : 18 November 2014

Delivered at : Perth

Finding of : Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order :

The names of the deceased and the deceased’s sister, and any identifying information, are suppressed.  The deceased is to be referred to as TS and the deceased’s sister is to be referred to as TAS.


Summary : The deceased was subject to a protection order at the time of his death and placed in the care of his grandparents.  The deceased had been well looked after by his grandparents in a caring, loving and safe environment.

The inquest focused primarily on what medical information was available that might assist in establishing a cause of death.  The care of the deceased in the period leading up to his death, as well as the circumstances of his death were also the subject of evidence.

On 14 October 2010 the deceased appeared to be normal and did not complain of being unwell.  He went to bed at approximately 9pm.  The next morning he was discovered lying unresponsive in his bed.  The deceased’s grandparents commenced cardiopulmonary resuscitation until the ambulance paramedics arrived.  Paramedics conducted observations of the deceased and certified life extinct.

After post mortem examination the forensic pathologist concluded that he was unable to identify a structural cause for the death and as such the cause of death was given as “unascertained”.  However, having excluded any structural cause and taking into account the deceased’s previous history of seizures, the forensic pathologist formed the opinion that the appropriate cause of death was “unascertained (consistent with epileptic seizure).  Alternatively, some pathologists use the term “SUDEP” or “sudden unexpected death in epilepsy”.  Additional evidence given at the inquest from Dr Walsh, a paediatric neurologist, supported the forensic pathologist’s original opinion that the death was a SUDEP death. 

The deceased had a reported history of seizures before being taken into care.  There was some thought that the seizures may have been related to non-prescribed medication given to the deceased.  After he was taken into care and the medication was ceased, no more seizures were reported and his health was seen to generally improve.  As a result, the source of the earlier seizures was not investigated further.  However, Dr Walsh’s review of the medical history was that the reported seizures were likely have been caused by a particular form of epilepsy.  This supported the conclusion that the deceased had an epileptic seizure the night he died.

The Coroner concluded that while the preferred approach would have been to conduct further investigations and explore the possibility of giving medication to the deceased to control seizures, it could not be said that his death would have been prevented if this had been done.  The Coroner concluded that while considerable research has been conducted into SUDEP, it is still the case no complete solution has been found to prevent it.

The Coroner was satisfied that there was nothing that the Department for Child Protection did or failed to do that contributed to the deceased’s death.

The Coroner found that the manner of death was by way of Natural Causes.

Catch Words : Death in Child Protection – Epilepsy - SUDEP – Natural Causes


Last updated: 10-Jan-2024

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