Coroner's Court of Western Australia

Inquest into the Death of Malakai Matiu Ward PARAONE

Inquest into the Death of Malakai Matiu Ward PARAONE


Delivered on : 4 September 2020

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 26 August 2016 Malakai Paraone died at Princess Margaret Hospital from complications in association with fulminant sepsis (Streptococcus pyogenes). He was seven months old.

At about 1.20 am on 23 August 2016, Malakai attended the ED at the Sir John of God Midland Hospital with his parents. He had not been moving his right elbow and had been crying with pain. His mother advised that he had pulled his elbow previously while playing with his brother. An X-ray showed no fracture and he stopped crying when his arm was positioned for the X-ray. An infection was excluded as a diagnosis and he was discharged. His parents were advised that he should be bought back to the ED if he developed a fever, became unwell or stopped moving his arm.

Malakai remained unsettled during the day on 23 August 2016. In the late morning he was taken to PMH by ambulance and was seen by a registrar and a consultant. He appeared to improve and was discharged home in the late afternoon. On 24 August 2016, he remained unsettled with coughing, diarrhoea and apparent fever, so his paternal grandmother took him to a GP who diagnosed viral upper respiratory tract infection and enteritis.

Malakai continued to be unsettled throughout the night so his grandmother took him to the Rockingham General Hospital ED in the early hours of the morning of 25 August 2016. Doctors realised that he was very unwell and commenced treatment for septicaemia with the help of an on-call consultant paediatrician. Arrangements were made to transfer Malakai to PMH.

On the way to PMH in the ambulance Malakai’s conscious state deteriorated. At PMH, he was unresponsive and had ineffective respiratory effort and an extensive purpuric rash. He underwent cardiorespiratory resuscitation and was placed on life-support. Overnight it became clear that he could not be resuscitated. He died on 26 August 2016.

The Deputy State Coroner found that Malakai’s death was preventable had he been diagnosed with sepsis earlier. However, streptococcal sepsis in general and sepsis arising from a deep-seated infection of the arm of an infant in particular are extremely challenging to diagnose even for competent, experienced clinicians.

Catch Words : Infant : Streptococcus pyogenes : Deep-seated infection : Sepsis : Septic shock : Natural Causes

Last updated: 1-Oct-2020

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