Coroner's Finding: BETTS Lawrence

Contributing factors

• ingestion of foreign material including soil, sand, and stones
• inadequate supervision in the rear garden on 26 April 2011
• inconsistent care protocols between two CARA facilities
• lack of formal documented care plan addressing known pica behaviour
• Goldenhar syndrome with associated developmental delay
• constipation increasing sigmoid volvulus risk
• dehydration and sepsis from bowel ischaemia and ulceration

Coroner's recommendations

1. That children placed under ministerial guardianship with identified disability be medically examined by a consultant paediatrician as soon as possible after placement
2. That all available information regarding medical history and disabilities be made available to carers
3. That respite care agencies appoint a key worker to each child; the key worker should oversee care across all facilities where the child is accommodated
4. That measures ensure carers adopt consistent approaches to management of a child's disability; care plans should be compiled in plain language, properly documented, regularly reviewed, include input from qualified medical practitioners, and be made available to the Guardian for Children and Young People
5. That the Minister ensure entities caring for children under her guardianship, especially those with disability, are adequately resourced and equipped to deliver appropriate care