Coroner's Court of Western Australia

Inquest into the Death of Child T (Name Suppressed)


Inquest into the Death of Child T (Name subject to Suppression Order)


Delivered on :11 February 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

There be no reporting or publication of the deceased’s name and any evidence likely to lead to the child’s identification. The deceased is to be referred to as Child T.

Summary : Child T died from pneumonia in association with bronchiolitis on 13 July 2019, he was two years and three months of age. At the time of his death, Child T was in the care of the CEO of the Department of Communities (the Department) and had been placed with a foster carer.

Child T and his sibling were taken into provisional care on 23 August 2018, because of concerns for their welfare. The Department placed the children with a foster carer who had demonstrated she was able to provide a safe, caring and nurturing environment for a child in need. During the time the children were in foster care, a departmental caseworker maintained regular contact with the carer and on 12 March 2019, the Children’s Court of Western Australia granted the Department’s application for a protection order in favour of the children.

Whilst he was in care, Child T was regularly seen by a doctor in relation to usual childhood ailments, including gastroenteritis and minor chest infections. There was a delay in him receiving all of the usual 12-month vaccinations, but his doctor did not feel this was related in any way to his death.

Child T attended his usual day-care centre on 12 July 2019. He seemed fine and was not showing any signs of a cough or the flu. When his carer collected him at about 5.30 pm, a staff member told her that Child T had just started coughing badly. Once at home, Child T was changed into his pyjamas and as a treat, he and his sibling had fast food for dinner. Child T ate some, but not all of his dinner and seemed tired. He was also coughing and his carer gave him a standard dose of Children’s Panadol. He seemed to settle and he was placed in his cot just after 7.30 pm. Although he was put on his back, he rolled onto his stomach which was his preferred sleeping position.

About an hour after Child T was placed in his cot, his carer thought she heard him coughing but when she listened at the bedroom door, there was no further noise. During the night, the carer woke two or three times thinking she heard the children. On each occasion, she got out of bed and listened at the open bedroom door, but there was no further noise.

The carer woke up at about 7.00 am on Saturday, 13 July 2019, and checked on Child T and his sibling. Both children appeared to be asleep.   Because it was the weekend, the carer wanted to let the children have a sleep-in and she thought a long sleep would be good for Child T’s cough. The carer’s former husband arrived at about 11.00 am and sometime later, Child T’s sibling woke up. The husband went to check on him and he and the child came into the lounge area. Just before midday, the carer went to wake Child T and found he deceased in his cot.

The Coroner noted that with the benefit of hindsight, it was unfortunate that the carer had not physically checked on Child T, but there was no evidence that had this occurred, Child T would not still have died. Although the Coroner commented on some missed opportunities on the part of Department in terms of providing intensive family support, he concluded that the standard of care, supervision and treatment that Child T received while he was in care was adequate.

Catch Words : Care, supervision and Treatment While in Care : Immunisations and Vaccinations : Natural Causes

Last updated: 19-Mar-2021

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