Inquest into the death of Baby C
Demographics
<1y, female
Date of death
2013-01-09
Finding date
2014-09-01
Cause of death
undetermined (chronic malnutrition ruled out; possible dehydration with electrolyte disturbances or infection, but no conclusive evidence)
AI-generated summary
Baby C, born prematurely at 32 weeks (1.64kg), was discharged from Alice Springs Hospital on 2 January 2013 medically well and appropriately. She was placed in foster care with Ms Preston, an exceptionally experienced and skilled carer. Over the following week, despite Ms Preston's dedicated efforts and experience managing feeding difficulties and bowel problems, Baby C's health declined significantly with marked weight loss (12% in final week). She died on 9 January 2013 at 6 months old. Autopsy findings were inconclusive; chronic malnutrition was ruled out by expert evidence of consistent pre-hospital growth. The coroner could not determine a precise cause of death but noted possible dehydration from poor feeding and diarrhoea, or less likely infection. No criticism was made of the Department of Health's discharge decision, DCF's care decisions, or Ms Preston's care. The coroner recommended establishing a telephone support protocol linking paediatric nurses with foster carers to provide accessible medical guidance for concerns like feeding, bowel problems, and infant lethargy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- difficulty feeding infant with formula despite experienced foster carer
- diarrhoea and bowel dysfunction
- weight loss of approximately 12% in final week of life
- possible dehydration
- failure to escalate to medical care despite infant appearing unwell
- delay in seeking urgent medical attention
Coroner's recommendations
- Strongly recommend that the Departments of Health and DCF work together with foster care agencies to establish a workable protocol whereby a clinical nurse or nurses experienced in paediatric issues would be available by telephone at first instance or in person as necessary to respond to health enquiries from foster carers looking after young babies, including matters such as feeding difficulties, bowel problems, and infant lethargy.
- The proposal should provide immediate or near-immediate response to medical problems to ensure early resolution and prevent escalation to critical illness.
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