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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