Inquest into the death of Lebron Douglas Martin
Deceased
Lebron Douglas Martin
Demographics
4y, male
Date of death
2017-12-13
Finding date
2019-11-22
Cause of death
respiratory failure secondary to pneumonia on a background of Niemann Pick Type C disease
AI-generated summary
Lebron Martin was a 4-year-old Aboriginal child with Niemann-Pick Type C disease, a progressive neurodegenerative disorder. He died from respiratory failure secondary to pneumonia in December 2017. Four months prior to his death, the Department of Territory Families removed him from parental care. The coroner found this removal was unjustified and violated the Convention on the Rights of Persons with Disabilities. The family had successfully managed Lebron's complex medical needs with appropriate support services (Good Beginnings) in 2016. When these services ceased, the Department failed to reinstate or provide alternative support despite the family's capacity being limited. The coroner concluded that rather than removing Lebron, the Department should have ensured continuing family support including assistance with feeding, transport to appointments, and coordination of medical care. This would have enabled Lebron to spend his final months with his loving family rather than in care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- removal from family care
- withdrawal of support services (Good Beginnings)
- failure to reinstate or provide alternative community support
- inadequate coordination between disability services and child protection
- assumptions about neglect without proper assessment of family circumstances
- food insecurity and poverty
- progressive neurological decline affecting swallowing and feeding
- poor planning for respite care arrangements while in alternative care
Coroner's recommendations
- The CEO Territory Families should ensure that staff have the training and resources to appropriately support children with disabilities and their families
Full text
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