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Inquest into the Death of MKP

Deceased

MKP

Demographics

15y, female

Date of death

2011-12-26

Finding date

2015-06-18

Cause of death

Seizure Disorder in association with Long Standing Hypoxic Ischaemic Encephalopathy (known severe cerebral palsy)

AI-generated summary

MKP was a 15-year-old girl with severe cerebral palsy (GMFCS level 5) and long-standing hypoxic-ischaemic encephalopathy who died from a seizure disorder in her foster home on 26 December 2011. She had progressive respiratory compromise with obstructive sleep apnoea and desaturations noted in the months before death. Her paediatrician had identified the need for a multidisciplinary meeting to discuss emergency management plans for her respiratory impairment, but this meeting had not been finalised by the time of her death. The coroner found no deficiency in her care by the foster family or Department, noting the Murphys provided exceptional, devoted care. The clinical lesson is that in children with severe neurological impairment and progressive respiratory dysfunction, timely formalisation of advance care planning and emergency protocols is essential, even when excellent day-to-day care is being provided.

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

Contributing factors

  • Obstructive sleep apnoea
  • Progressive respiratory depression with age and growth
  • Respiratory drive impairment due to brain damage
  • Inability to self-protect airways due to severe immobility
  • Lack of finalised emergency management plan
  • Increased muscle tone interfering with airway protection

Coroner's recommendations

  1. Completion of multidisciplinary meeting to discuss emergency management plans for children with progressive respiratory impairment
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