Coronial
WAhome

Inquest into the Death of ST

Deceased

ST

Demographics

0y, female

Coroner

Coroner King

Date of death

2014-11-20

Finding date

2017-03-29

Cause of death

Pneumonia in an infant with surgically repaired congenital heart disease, prematurity and failure to thrive

AI-generated summary

A 9.5-month-old girl with complex medical history (prematurity at 29 weeks, congenital heart disease status post multiple repairs, necrotising enterocolitis with ileostomy, failure to thrive) died from acute pneumonia caused by rhinovirus, norovirus, and secondary Staphylococcus aureus infection. She was in out-of-home care with her grandparents at the time of death. The coroner found all medical care was appropriate, including hospital-based care at KEMH and PMH and community nursing via Hospital in the Home. While the HiTH nurse did not perform vital signs observations during a visit on 18 November when the child was unsettled, the coroner accepted this was not substandard practice. The death was from natural causes and essentially unpreventable given the child's significant medical vulnerabilities and the rapid progression of pneumonia.

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

Specialties

neonatologycardiothoracic surgerypaediatricspathology

Drugs involved

ibuprofenpromethazine

Clinical conditions

pneumoniacongenital heart disease (atrio-ventricular septal defect)necrotising enterocolitisprematurityfailure to thrivemicrocephalyhypoxiaStaphylococcus aureus infectionrhinovirus infectionnorovirus infection

Procedures

bowel resectionileostomy formationpulmonary artery bandingcongenital heart defect repairmitral valve replacement (Hancock tissue valve)pacemaker insertion

Contributing factors

  • Rhinovirus respiratory infection
  • Norovirus infection
  • Secondary Staphylococcus aureus pneumonia
  • Microcephaly with reduced brain weight affecting arousal response to hypoxia
  • Immune deficiency secondary to prematurity and complex medical history
  • Congenital heart disease with recent surgical repair
Full text

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