Inquest into the Death of TP (a child) (Subject to a Suppression Order)

Contributing factors

• Refractory epilepsy despite multiple anti-epileptic medications
• Previous episode of vomit aspiration during seizure six months earlier, not communicated to camp staff
• Use of baby monitor at home for overnight monitoring, not communicated to camp staff
• Seizure during sleep causing vomiting and aspiration of gastric contents
• Lack of medical clearance documentation from treating neurologist for camp participation

Coroner's recommendations

1. Hale School Sony Camp to implement a procedure requiring a signed and dated certificate from the child's treating medical practitioner certifying the child as suitable to attend the camp
2. The medical certificate should include a description of the child's medical condition, its particular consequences for the individual child, medical treatment needs, and special care needs
3. The certificate should be prepared by a medical practitioner with high-level understanding of daily living and care requirements for the special needs child, with particular focus on information needed by camp medical supervisors
4. Hale School staff to formally review medical procedures at the completion of every future Sony Camp to identify further improvements