Coroner's Court of Western Australia

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

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

Delivered on : 9 January 2023

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order :

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

Summary: On 19 June 2013 Child F died in South Hedland as a result of respiratory failure in association with pneumonia on a background of Child F’s diagnosis of metachromatic leukodystrophy, a rare neurological disease. Child F was a child in the care of the CEO of the Department of Communities at the time of his death, so his death was a reportable death, but his death was not reported to the State Coroner until May 2021.

Child F was known to the Department of Communities from an early stage. They had received reports of domestic violence begin perpetrated against his mother during her pregnancy with him, and after his birth. Although she then separated from Baby F’s father, concerns were raised about Child F’s mother’s ability to care for him and his older sister. There was ongoing contact between Communities and Child F’s relatives, which eventually lead to an informal arrangement in August 2010 that Child F and his older sister would live with a relative in Karratha. However, after a short time, Child F’s mother indicated she intended to take the children back into her care. After some consideration, it was decided that the case had not reached the statutory threshold for intervention, so the children were returned to their mother in November 2010.

On 17 December 2010, staff from the Manwarnkarra Health Service raised some concerns about Child F’s presentation with bruises, and on 24 December 2010, Baby F was brought to Nickol Baby Hospital with respiratory issues and significantly swollen legs. Doctors determined that Baby F had a number of very serious injuries to his legs and other parts of his body, and he was sent to Princess Margaret Hospital in Perth for treatment. Communities substantiated physical harm of Child F and took him into provisional care on 26 December 2010. It was suspected that Child F’s mother’s new partner had caused the harm to him, but a police investigation was unable to find sufficient evidence to lay charges against any person.

When Child F was discharged from hospital on 13 January 2011, he was placed in foster care, then a group home, until a suitable home could be found for him. He was eventually placed with a family carer, who was the partner of his biological father, on 1 April 2011. He lived from that time with his carer and his older sister, as well as his biological father on occasion. He was provided with a loving and caring home and made improvements, but then began to regress. After various investigations, he was eventually diagnosed with Metachromatic Leukodystrophy (MLD), a rare neurodegenerative disorder which causes cells of the central nervous system to stop working. It is a genetic disorder that is inherited. The disease has a poor prognosis, and Child F was not expected to live beyond five years of age. Child F was provided with excellent medical and personal care, and there was a good relationship between Communities staff, his doctors and his carer. Child F’s care was eventually made palliative and he died in his carer’s arms and in the presence of his father on 19 June 2013 after he developed pneumonia and suffered respiratory failure.

Initially, a medical death certificate was issued and Baby F’s death was not reported to the State Coroner, despite his death being a reportable death as he was a child in care. The error was eventually identified and his death was belatedly reported to the coroner on 7 May 2021, prompting a coronial investigation and then mandatory inquest.

At the conclusion of the inquest, the Coroner was satisfied Child F died as a result of respiratory failure in association with pneumonia in a child with metachromatic leukodystrophy. The manner of death was natural causes. The Deputy State Coroner was satisfied that the treatment, supervision and care provided to Baby F prior to his death was of a high standard.

Catch Words : Mandatory Inquest - Care, supervision and Treatment While in Care: Department of Communities

Last updated: 6-Feb-2023

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