Coroner's Court of Western Australia

Inquest into the Death of Child AM (Name Subject to Suppression Order)

Inquest into the Death of Child AM

Delivered on : 22 June 2021

Delivered at: Perth

Finding of : Coroner Urquhart

Recommendations: Yes

Recommendation No 1

In order to address childhood obesity in remote and regional areas, I recommend the Western Australian government considers introducing an outreach service for the Healthy Weight Service Clinic at Perth Children’s Hospital.

Recommendation No 2

In order for the program offered by the Healthy Weight Service Clinic to be culturally appropriate for Aboriginal families, I recommend that the Western Australian government considers introducing, on a permanent basis, the pilot program offered by the Healthy Weight Service Clinic from mid-2015 to early-2017.   

Orders/Rules: N/A

Suppression Order: Yes

The deceased’s name is suppressed from publication.  The deceased should be referred to as Child AM in any external publication and no information should be published that might lead to the identification of the deceased.

Summary: At the time of her death Child AM was in the care of the Department of Child Protection and Family Support (the Department).  Child AM was born in a remote community in the East Kimberley on 15 September 2011.  She was the first child of her parents and her birth weight of 2.82 kg was regarded as low.  Child AM participated in a traditional Aboriginal ceremony in the early days of her life to help her gain weight.  It appears she soon developed a voracious appetite.  Her family are of the view that the Aboriginal ceremony was the cause of Child AM’s on-going weight issues.

From 17 November 2011 to 22 March 2014 Child AM was evacuated from the remote East Kimberley community where she lived on 12 occasions with obesity related issues.  She was mainly admitted to the Broome Hospital but also spent time in Royal Darwin Hospital and Halls Creek Hospital.

Child AM suffered from rapid excessive weight gain, global development delay, obstructive sleep apnoea, asthma and on occasion periods of loss of consciousness.   The health consequences of Child AM’s significant obesity were substantial and apart from obstructive sleep apnoea included obstructive-hypoventilation syndrome requiring supportive ventilation, right heart ventricular hypertrophy, severe pulmonary hypertension, hyperinsulinemia and hypercholesterolemia.   At the young age of 2 years, 3 months, Child AM’s obesity was considered a threat to her life based on the complications then of severe asthma and her obstructive sleep apnoea.

Child AM was placed into provisional protective care of the Department’s CEO from 8 May 2014 until 17 August 2014 and again from 30 January 2014 until her death on 4 September 2015.  On 29 June 2015 following three months hospitalisation Child AM was discharged into the care of a new foster carer.  Her weight had been reduced significantly and she had switched from a CPAP machine to a BiPAP (bi-level positive airways pressure) machine to manage sleeping.    

On 1 September 2015 Child AM had a respiratory clinic appointment where she was examined by a doctor specialising in endocrinology.  It was noted that her weight was stable at 36 kg, she was more active, had improved sleep and could be distracted from food-seeking behaviours.  She had a chest infection and was treated with antibiotics prescribed by her GP.  The plan was to continue on the BiPAP machine and the melatonin to assist with sleep.

 On 3 September 2015 Child AM woke up with diarrhoea.  She had follow-up appointments with an occupational therapist and physiotherapist and did not appear well.  Between 6.30 pm and 7.00 pm she ate dinner and then laid down on the floor to watch television.   She then fell asleep.  Her carer was unable to lift her as she was too heavy, so she waited until 11.00 pm when her partner came home.  On attempting to lift her, the partner found her to be unresponsive.  The female carer commenced CPR, however Child AM’s jaws was locked.  The carer contacted her mother who was a nurse and the mother took over resuscitation until paramedics arrived at 11.16 pm.

Paramedics found that Child AM had no output, no respiratory effort and was cold to touch.  Paramedics were unable to intubate due to the spasm of the jaw.  An oropharyngeal was inserted with some difficulty.  Child AM was then conveyed to Joondalup Health Campus (JHC) arriving at 11.52 pm.  At JHC resuscitation efforts continued but Child AM remained asystole and CPR was ceased at 12.17 am on 4 September 2015.  Child AM was certified as having died.

A forensic pathologist conducted a post mortem examination and after investigations and information provided formed the opinion the cause of death was bronchopneumonia in an infant with obstructive sleep apnoea.

The Coroner was satisfied Child AM had a large range of medical complications that arose shortly after her birth.  Many of the complications arose from her obesity, most notably her obstructive sleep apnoea.  In combination, those medical conditions meant that Child AMs life was always a risk.  The Coroner found that Child AM’s death occurred by way of natural causes.    

Catch Words: Child in Care : Childhood Obesity : Foster Carers : Supervision, Treatment and Care : Natural Causes


Last updated: 29-Sep-2021

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