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

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

Delivered on : 10 November 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : Yes

On the basis that it would be contrary to the public interest, I make the following order pursuant to section 49(1)(b) of the Coroners Act 1996 (WA): There be no reporting or publication of the deceased’s name and/or any evidence likely to lead to the child’s identification.  The deceased is to be referred to as “Child ML”.

Summary :

Child ML died from pneumonia complicating a viral respiratory illness with acute combined drug effect in a young girl with cerebral palsy, recurrent aspiration, and chronic seizure disorder on 24 February 2019.  She was seven years of age.

Child ML was diagnosed with spastic quadriplegia, a severe form of cerebral palsy that causes jerking movements and stiffness in the limbs.  She was unable to control her head, trunk and limbs and was confined to a wheelchair.  She was also diagnosed with a seizure disorder, which was relatively well controlled, and she had chronic lung disease. 

Child ML did not have a “safe swallow or gag reflex” and was unable to protect her airways, or safely consume food or drink orally.  As a result, Child ML was eventually fed by means of a percutaneous endoscopic jejunostomy tube (PEJ tube), which passed through her abdominal wall into her jejunum.

Child ML was admitted to Bunbury Regional Hospital (BRH) on 21 February 2017, and diagnosed with severe weight loss and dehydration.  Although there were concerns she would die in the days after her admission, over the next six weeks, Child ML regained the weight she had lost and she was discharged into her mother’s care on 5 April 2017.  However, Child L was readmitted to BRH on 7 April 2017 with very high levels of sodium In her blood (hypernatremia), a serious and potentially fatal medical condition.

Following these two admissions, and after years of repeated welfare concerns, Child ML was finally taken into the care of the Department of Communities (the Department) on 28 April 2017.  Child ML was placed into foster care in August 2017, and the coroner concluded that Child ML’s foster carer had provided an excellent standard of care to Child ML, and had managed her complex care needs in a diligent, skilled, and caring manner.

After carefully considering all of the available evidence, the coroner also concluded there were inadequacies in the standard of supervision and support provided to Child ML, and her carers whilst she was in the Department’s care.  This included inadequacies in the support provided to Ms B generally, and to Ms A during supervised and unsupervised contact visits with Child ML.

At the time she died, Child ML was having a supervised access visit with her mother.  Following her death, Child ML was found to have a number of medications in her system, including high levels of paracetamol and gabapentin, and an overdose of codeine.

Child ML was not prescribed codeine, and the feeding bags and tubes which were attached to her body at the time of her death were not seized and analysed.  Further, the people who had access to Child ML in the period leading up to her death, including Child ML’s mother, all flatly denied having given Child ML any medication containing codeine (even inadvertently).

The coroner noted that despite these denials, the evidence established that the levels of codeine and morphine detected in Child ML’s system were “strongly implicated” as having contributed to her death and had come from a large dose of codeine which was given to Child ML a few hours before her death.

On the basis of the available evidence, the coroner was unable to determine how and/or why Child ML came to have codeine in her system, a situation he described as “clearly unsatisfactory and frustrating”.

The coroner made three recommendations aimed at improving police investigations and the Department’s management of children with complex care needs.

Catch Words : Department of Communities : Supervision, treatment and care : Multiple co-morbidities : Opioids : Respiratory complications : First Aid Training : Complex medical needs : Open Finding


Last updated: 1-Dec-2023

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