Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia
Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

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

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

Delivered on :26 August 2021

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

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

Summary : At the time of his death Baby E was in the care of the Chief Executive Officer of the Department of Communities.  Baby E was seven months old when he died on 1 February 2020 from complications of VATER syndrome and sacrococcygeal teratoma.

Baby E was born on 1 July 2019 at 30 weeks and 6 days gestation by emergency caesarean section at King Edward Memorial Hospital.  He required resuscitation, intubation, and ventilation at birth.  The pregnancy of Baby E’s mother was complicated by her on-going use of cannabis and methylamphetamine.  She had developed oligohydramnios and an ultrasound revealed the Baby E had intrauterine growth retardation, an absent left kidney, and right renal hydronephrosis.  Shortly before his birth, Baby E was diagnosed with hyaline membrane disease and apnoea of prematurity.  In addition to having no left kidney, Baby E had an absent anus and multiple skeletal abnormalities.  He also required antibiotics to treat a suspected infection.

Baby E after his birth was transferred to Perth Children’s Hospital where he remained in their care for over 5 months.  During this time, Baby e underwent many surgeries.  On 24 December 2019, Baby E was discharged from PCH into the care of his maternal grandmother.  On 31 January 2020 his grandmother noticed he had intermittent difficulty in breathing and episodes of twitching.  On 1 February 2020 Baby E’s grandmother could feel a solid mass on the right-side of his abdomen.  The made plans to take him to hospital, however, as she was leaving the house, Baby E suddenly became limp and unresponsive and so she can ambulance.

Baby E was taken to the Rockingham Hospital and diagnosed with acute gut catastrophe.  He was given intranasal fentanyl and intramuscular midazolam, to keep him comfortable.  Baby E died in his grandmother’s arms at 8.30am.

The Coroner was satisfied with the care, supervision and treatment provided by the Department to Baby E which was of an acceptable standard.  The Coroner commended Baby E’s grandmother for the love and care she extended to her grandson during his short life.

Catch Words : Care, Supervision and Treatment : Department of Community Protection : Multiple Health Conditions : Standard of Medical Care : Natural Causes


Last updated: 19-Mar-2022

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