Inquest into the death of Skye Bree Burnett
Deceased
Skye Bree Burnett
Demographics
0y, female
Date of death
2002-05-25
Finding date
2003-12-15
Cause of death
sudden death in an infant with broncho-pulmonary dysplasia
AI-generated summary
A 74-day-old premature infant (27 weeks gestation) died unexpectedly at home three days after discharge from hospital. Post-mortem examination revealed broncho-pulmonary dysplasia (BPD), which was clinically silent and undetectable before death. Expert review found the hospital care was excellent and discharge decisions appropriate. Contemporary paediatric evidence shows 50% of 27-week premature infants develop BPD to this degree, and home monitoring would not have prevented this death. The main clinical lesson concerns communication: parents were initially told the death was SIDS, then autopsy findings revealed BPD, creating confusion and distress. The coroner found that preliminary diagnoses should include appropriate qualifications, and pathology findings should be communicated to families in consultation with treating clinicians when possible. The death was not preventable—the condition could not have been identified or managed differently had it been known.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- broncho-pulmonary dysplasia (clinically silent, undetectable pre-mortem)
- extreme prematurity (27 weeks gestation)
- risk inherent to premature infants
Coroner's recommendations
- Note that parental preparation for transition from acute to step-down care may reduce anxiety when babies are transferred between care levels
- Medical practitioners should provide more rather than less information to parents of premature babies at discharge when there is any doubt or no reason not to do so
- Preliminary opinions on cause of death should include appropriate qualifications and acknowledgement that autopsy findings may reveal additional information
- Pathology findings should ideally be communicated to families in consultation with treating clinicians where practicable, rather than in isolation
- Consider establishing visiting specialist paediatric pathology service for the Territory (acknowledging logistical and cultural difficulties with interstate transfer of bodies)
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