Coronial
QLDhospital

(C) a 15 month old child

Deceased

C

Demographics

1y, male

Coroner

Lock

Date of death

2005-11-01

Finding date

2011-06-24

Cause of death

Complication of burns and trauma to the mesenteric artery

AI-generated summary

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unknown cause. The child deteriorated in a manner inconsistent with typical burn injuries. Critical clinical lessons include: (1) severe supervision failures by parents; (2) failure of government agencies (NSW and Queensland child protection and mental health services) to share critical child protection history due to witness protection program complications; (3) inadequate assessment protocols by child safety officers who did not enter the home or verify mental health service involvement; (4) missed opportunity for SCAN referral when substantiated risk was identified; (5) the mesenteric injuries likely pre-dated the burns and suggested prior unwitnessed trauma. Preventable through proper parental supervision, adequate inter-agency information sharing despite witness protection concerns, and potentially through hot water temperature regulation.

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

Specialties

paediatricsplastic and reconstructive surgerypaediatric surgeryintensive carepsychiatryemergency medicine

Error types

communicationsystemdelay

Drugs involved

risperidonefluvoxamine

Clinical conditions

severe thermal burns (55% body surface area)scalding injurymesenteric artery tearsintestinal ischaemiagastrointestinal gangrenebowel necrosissubdural haemorrhageabdominal compartment syndromesepticaemiadisseminated intravascular coagulationmaternal paranoid schizophrenia with depressive featuresmaternal agoraphobia with panic disordermaternal non-compliance with antipsychotic medicationchild neglect

Procedures

emergency laparotomypigtail catheter insertion

Contributing factors

  • Prolonged unsupervised time in bath with hot water (10-15 minutes)
  • Hot water temperature of 65°C, well above safe limits
  • Previous traumatic mesenteric artery tears of undetermined cause
  • Failure of NSW and Queensland child protection services to share historical child protection information due to witness protection program
  • Incomplete child protection assessment by Queensland child safety officers
  • Failure to enter home or verify mental health service involvement during assessment
  • SCAN referral not made despite substantiated risk of harm
  • Non-compliance of mother with mental health treatment
  • Family instability with father facing incarceration
  • Inadequate inter-agency communication between mental health and child protection services
  • Parental inattentiveness to children's welfare and whereabouts

Coroner's recommendations

  1. The cross jurisdictional issues raised by this case be considered by the Witness Protection Program National Meeting so common ground amongst all witness protection programs can be reached as to how an exchange of information between relevant agencies in relation to child protection concerns can best be delivered
  2. The Queensland Government ensure all Queensland Housing stock it has responsibility for comply with AS 4032[1] 2-2005 and AS 3500[1] 4.1 1997 such that hot water tempering valves are installed in all premises notwithstanding that the hot water systems were installed prior to 30 April 1998
  3. The Department of Infrastructure and Planning investigate and considers retrospective mandating of the Australian Standards in respect to hot water tempering valves at point of sale and lease in a manner similar to that now adopted for smoke alarms, electrical safety switches and swimming pool fences
Full text
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