Deceased
Daniel Thomas Wright
Demographics
8y, male
Coroner
Gallagher
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.
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Specialties
Error types
Clinical conditions
Procedures
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Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
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