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

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

Delivered on : 8 December 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :

The Department of Communities (the Department) should examine the feasibility of providing mandatory annual training for carers who look after children with medical conditions that may require the administration of emergency medication.  The Department should also consider how health navigators could assist in facilitating this crucial training.

Suppression Order:

Suppression of the deceased’s name from publication and any evidence likely to lead to the child’s identification.  The deceased is to be referred to as “Child B”.  RVC Fogliani, State Coroner (23.05.22)

Summary : Child B died on 8 December 2020 at Perth Children’s Hospital from a hypoxic brain injury.  At the time of his death, Child B was in the care of the Director General of the Department of Communities (the Department) and was 3 years old.

Child B had a complex medical history including significant endocrine issues, cardiac defects, blindness, and developmental delay.  As a result of his congenital conditions, Child B had adrenocorticotrophic hormone (ACTH) deficiency which impaired his body’s ability to release a hormone called cortisol.  Cortisol plays an important role in controlling the body’s response to stress, as well as maintaining blood pressure, salt balance, and the amount of sugar in the blood, and Child B required medication, in the form of synthetic cortisol (hydrocortisone), three times per day.

Neither of Child B’s parents were able to provide him with the care his complex needs demanded, and he was apprehended and taken into provisional care and protection on 2 January 2018, and he was discharged from hospital and placed with a foster carer.  The Children’s Court of Western Australia made a care and protection order until age 18-years in relation to Child B on 11 November 2019.

Child B’s foster carer was proactive in attending to his medical needs and provided him with a loving and stimulating home in which he thrived.  Because he was prone to adrenal crises, his foster carer was given some training in how to inject him with an emergency dose of hydrocortisone.  However, this training occurred only once in 2018.

After spending the day at the Perth Museum on 29 November 2020, Child B was given a bath and a bottle of baby formula, which was used to feed him because of his medical conditions.  Other than a slightly elevated temperature, Child B seemed fine when he was put into his cot by his foster carer at about 8.30 pm.  When his foster carer checked on him at about 6.20 am on 30 November 2020, he was unresponsive and his foster carer called emergency services.

Child B was taken to hospital by ambulance, but his condition deteriorated, and he was declared brain dead at 12.28 pm on 8 December 2020.

At the conclusion of the external post mortem examination, Dr White expressed the opinion that the cause of Child B’s death was: “Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and status epilepticus in a child with a recent febrile illness and a history of septo-optic dysplasia and panhypopituitarism, medically palliated”.

In layperson’s terms, the forensic pathologist’s opinion as to the cause of death refers to the fact that Child B had experienced a brain injury due to lack of oxygen, which complicated shock caused by low blood sugar, in the context of his known medical conditions.

The coroner was satisfied that the supervision, treatment and care Child B received while he was in care was of very good standard.

The coroner made one recommendation aimed at improving the administration of emergency medication to children in the Director General’s care.

Catch Words : Death in Care: Natural Causes : Adrenal crisis : Emergency dose of hydrocortisol

Last updated: 2-Feb-2023

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