Coronial
NThospital

Inquest into the death of Ruby Blitner

Deceased

Ruby Blitner

Demographics

7y, female

Date of death

2016-07-26

Finding date

2017-08-10

Cause of death

respiratory failure from severe scoliosis due to Murray Valley encephalitis

AI-generated summary

Ruby Blitner died from respiratory failure secondary to severe scoliosis caused by Murray Valley encephalitis acquired at age two. Her clinical course involved progressive respiratory compromise, recurrent aspiration pneumonia, and progressive spinal deformity. The coroner found that the care, supervision and treatment provided to Ruby was appropriate. A Do Not Attempt Resuscitation order had been established after discussion with family in October 2015, restricting interventions to oxygen, suctioning, antibiotics and physiotherapy without intubation or mechanical ventilation. On admission with aspiration pneumonia on 25 July 2016, she deteriorated rapidly with respiratory and renal failure despite appropriate initial management. No clinical errors were identified. Administrative issues concerning police investigation delays and departmental file accessibility were noted but addressed through improved processes.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsinfectious diseasesintensive carepalliative careorthopaedic surgerygeneral practice

Clinical conditions

Murray Valley encephalitisacquired brain injury with spastic quadriplegic cerebral palsyscoliosisrestrictive lung diseaseepilepsyaspiration pneumoniarespiratory failurerenal failure

Procedures

percutaneous endoscopic gastrostomy insertionorthopaedic hip proceduresintubation (historical, during acute phase of Murray Valley encephalitis)

Contributing factors

  • severe spinal scoliosis restricting chest expansion
  • progressive neurological disability from acquired brain injury
  • recurrent aspiration pneumonia
  • restrictive lung disease
  • progressive respiratory decline despite appropriate management

Coroner's recommendations

  1. Police to implement high level of supervision and monitoring of coronial briefs, with Assistant Commissioner Crime and Commander Crime having overall oversight of deaths in care or custody investigations
  2. Police to ensure deaths in custody or care are supervised by Superintendent Major Crime, with appropriate support for first-time investigators
  3. Department of Children and Families to immediately copy current files when requested by investigators rather than requiring all requests to pass through Information and Privacy Unit with redaction delays, to preserve coronial independence
  4. Department of Children and Families to update reporting templates to prompt reporting of all deaths to Coroner's Office, regardless of whether death was expected
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.