Coroner's Court of Western Australia

Inquest into the Death of ST

Delivered on 29 March 2017 at Perth.

Finding of Coroner King.

Suppression Order

No report may be published of any part of the proceedings or of the evidence given at this inquest that could lead to the identification of the deceased or her family.


The deceased was born prematurely with congenital heart disease. She underwent several surgeries to repair the heart defect. She was placed in the provisional care of the Chief Executive Officer of the Department of Child Protection and Family Support and, upon release from hospital, was placed into the care of her paternal grandparents.

The deceased was cared for by her grandparents at their home with the assistance of nurses from Hospital in the Home.

On 18 November 2014 Hospital in the Home nurse attended the deceased to weigh her, to change her catheter and to drop off supplies of anticoagulant. The deceased did not appear to be unwell.

On 20 November 2014 at about 7:30am the deceased’s grandmother gave the deceased a sponge bath and set up a feed for her through a nasal gastric tube. She left the house between 10:30am and 11am and, after she returned, checked on the deceased regularly. The deceased appeared to be sleeping.

At about 1:15pm the grandmother found the deceased lying on her back with her eyes open, not breathing. The grandmother called for an ambulance and administered CPR.

Ambulance officers took the deceased to the Armadale Kelmscott Hospital, but she could not be revived.

On the basis of a forensic pathologist’s report, the Coroner found the cause of death to be pneumonia in an infant with a history of surgically repaired congenital heart disease, prematurity and failure to thrive. The Coroner found that death occurred by way of natural causes.

The Coroner found that those providing care to the deceased had acted reasonably and appropriately.

Catch Words

Premature : Infant : Natural Causes : Hospital in the Home.

Last updated: 25 August 2022

[ back to top ]