Coroner's Court of Western Australia

Inquest into the Death of KLD (Subject to Suppression Order)

Inquest into the Death of KLD (Subject to Suppression Order)

Delivered on : 30 June 2017

Delivered at : Perth

Finding of : Deputy State Coroner

Recommendation : Yes

Recommendation No.1
I recommend that on the transfer of children in care from one location and set of carers to another, there be appropriate assessment by consultant paediatricians in the new location to record a child’s welfare and progress. This is on top of and in addition to their annual assessments.

Recommendation No.2
I recommend all children transferred from one location to another have a case worker. Only successful long term foster placements should be placed on a monitored list, after a suitable period of reasonable review.

Recommendation No.3
I recommend all contact of DCP workers with children in care be recorded and appropriately assessed in a group meeting to ensure there is adequate supervision of the care and treatment provided to children in departmental care.

Recommendation No.4
I recommend resourcing for the State Mortuary to be provided with a CT scanner. It would assist the forensic pathologists to have appropriate technology for their investigations and enable more compatibility of language between pathologists and clinicians.  In evidence Dr Lam indicated the PMH CT scanner was state of the art and would be available on opening of the new children hospital, which hoped to have raised funds by then for new improved technology in the form of optical coherence tomography to assist PMH clinicians with imaging.

Orders/Rules : N/A

Suppression Order : Yes

The name of the deceased and any identifying information are suppressed from publication. The deceased is to be referred to as KLD.

Summary : The deceased was a 21 month old female Aboriginal child in the care of the Department of Child Protection in August 2012 when she died.

The deceased was placed in the care of carers in Joondalup with supervised access to her biological parents. The deceased initially responded very well while in the care but the difficulties with access visits and her biological parents made it preferable for the deceased to be moved to Kalgoorlie where her biological parents had supportive family.  DCP attempted to find carers in the Kalgoorlie area but were unsuccessful and eventually relative carers on the deceased’s mother side were proposed as suitable carers.  The deceased moved to Kalgoorlie in March 2012.  The deceased was the youngest in the household and her foster mother discovered she was pregnant.

The deceased contracted a respiratory infection for which she was initially taken to the doctor but appear to have taken a long time to recover. The deceased suffered some incidents of injury, probably accidental which appears to have gone unnoticed.  Her progress stagnated and rather than progressing as a lively, health toddler, she began to show signs of withdrawal which were not acted upon.  The Deputy State Coroner noted that the deceased’s apparent withdrawal also corresponded to the time frame over which the Department of Child Protection at the Kalgoorlie office became solely response for the deceased and she had no case worker.  The deceased’s biological parents noted this withdrawal, but did not consider it to be of as much concern as later was proved to be warranted.  They were reassured by the fact they believed she was in care and the Department of Child Protection should be aware of any problems.

On 16 August 2012 following a supervised access visit at which the deceased was noticeably quiet and withdrawn, she was returned to her foster carers home in a drowsy condition. At some stage following her return home she was placed on the couch and suffered a fall, the exact parameters of which remain a little unclear.  The deceased’s foster mother picked her up and she suffered a fit with her eyes rolling back in her head.  The deceased’s foster mother did not have a telephone to call for help so she gathered the other children and drove the deceased’s to hospital as quickly as she could.

The deceased remained in cardiorespiratory arrest until she was stablished at Kalgoorlie Regional Hospital. She had suffered irreparable brain damage and despite a transfer to Princess Margaret Hospital and the best care the prognosis for the deceased could not be improved and was declared brain dead.  She was maintained on life support until family gathered and could say their goodbyes.

There was significant dispute between the clinicians involved in the care of the deceased and the neuropathologist over the reason for the deceased’s death. All were agreed she suffered hypoxic brain injury but the reasons for the brain injury were never agreed which made the issue of appropriate supervision, treatment and care difficult to elucidate.

The Deputy State Coroner made three recommendations to the Department for Child Protection in respect to an assessment be made by a consultant paediatrician in the new location to record a child’s welfare and progress, and the allocation of a case worker when a child is transferred from one location to another and finally, for all contact of Department workers with children be recorded to ensure there is adequate supervision of the care and treatment.

The Deputy State Coroner made a fourth recommendation relating to the resourcing for the State Mortuary to be provided with a CT scanner.

The Deputy State Coroner concluded that the deceased was well loved, but with appropriate review it would have become increasingly clear the deceased was not being cared for or supervised appropriately by the Department of Child Protection.

Catch Words : Foster Children in the care of the Department of Child Protection : Open Finding.


Last updated: 30-Apr-2019

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