Inquest into the death of Daniel Thomas Wright
Deceased
Daniel Thomas Wright
Demographics
<1y, male
Date of death
2019-03-30
Finding date
2025-07-15
Cause of death
prematurity-associated lung and bowel disease
AI-generated summary
Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associated lung and bowel disease while in parental care. Critical clinical lessons include: (1) his weight loss of 10% in final 10 days, indicating nutritional crisis, was not recognised as a medical emergency requiring admission; (2) growth charts were not consistently referenced to centiles despite available corrected-age charts; (3) nasogastric feeding was not offered despite poor oral intake; (4) discharge decisions on 28 February and 19 March 2019 relied on overly optimistic assessment of parents' capacity despite documented intellectual disabilities and communication difficulties; (5) treating clinicians were unaware of child safety concerns and multiple home-visit observations; (6) information sharing between hospital and child safety was inadequate; and (7) clinical escalation pathways for declining medically vulnerable infants were not activated.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- failure to thrive with documented weight loss
- inadequate weight monitoring despite available growth charts
- failure to recognise 10% weight loss in final 10 days as medical emergency
- inadequate feeding support—nasogastric feeding not offered despite poor oral intake
- overly optimistic assessment of parents' capacity to care for complex-needs infant
- parents with intellectual disabilities and acquired brain injury unable to understand or follow complex feeding plans
- inadequate communication between hospital clinicians and treating team regarding concerns
- clinicians unaware of child safety concerns and multiple home-visit observations documenting deterioration
- discharge decisions made without full awareness of escalating safeguarding concerns
- child safety intervention with parental agreement (IPA) not appropriate given medical complexity and parental limitations
- inadequate information sharing between Queensland Health and Child Safety
- SCAN meeting held after rather than before discharge, limiting opportunity for coordinated risk assessment
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