Coroner's Court of Western Australia

Inquest into the Death of ST

Inquest into the Death of ST

Delivered on : 29 March 2017

Delivered at : Perth

Finding of : Coroner King

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : Yes

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.

Summary : 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 CEO 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 7.30 am 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 10.30 am and 11.00 am and, after she returned, checked on the deceased regularly.  The deceased appeared to be sleeping.

At about 1.15 pm 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: 10-Jul-2024

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