Inquest into the death of Harland SUTTON
Deceased
Harland Sutton
Demographics
<1y, male
Date of death
2015-12-15
Finding date
2021-12-20
Cause of death
Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
AI-generated summary
A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should not have been present. Despite extensive investigation, the source of the frusemide could not be definitively determined, though paramedics had access to the drug. Expert evidence indicated frusemide was unlikely to have caused death. The death was classified as Sudden Unexpected Death in Infancy (SUDI), likely related to unsafe sleep position on soft objects combined with identified SUDI risk factors including prematurity, low birth weight, and paternal smoking. Key clinical lessons include the importance of accurate medication records, proper management of dangerous drug storage, and understanding that SUDI remains largely unexplained despite identified risk factors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- unsafe sleep position - prone on soft objects
- soft objects in sleep environment (pillows, doona)
- prematurity at birth (30 weeks gestation)
- low birth weight (1725g)
- paternal smoking (passive exposure)
- possible aspiration
- unexplained presence of frusemide in toxicology
Coroner's recommendations
- NSW Ambulance Service to conduct complete review of processes for local registers of non-registered medications to ensure greater accuracy and accountability
- Review method by which registers are updated and recorded to differentiate between: (1) restocking medication used in clinical treatment, (2) restocking out of date medication which is removed, and (3) replacing damaged stock
- Require replaced stock to be handed into control of station manager/controller
- Review frequency and conduct of regular and random audits of medication registers
- Consider introducing electronic recording system to record who accessed registers and identify discrepancies in real-time (noted budget constraints currently limit this to restricted medications only)
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