Coronial
WAhospital

Inquest into the Death of Child KT (Name Subject to Suppression Order)

Deceased

Child KT

Demographics

7y, male

Coroner

Coroner Linton

Date of death

2016-11-23

Finding date

2019-07-30

Cause of death

cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acute respiratory deterioration on a background of chronic respiratory disease secondary to cerebral palsy

AI-generated summary

Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding and multiple medications. After a severe respiratory event in 2015 requiring ICU admission and ventilation, a palliative care plan was established with a 'not for resuscitation' order agreed by medical staff, foster parents, and biological mother. His final admission in October 2016 involved multidisciplinary care including respiratory, palliative care, and complex care teams. He deteriorated progressively and died comfortably with family present. The coroner found care and supervision to be of very high standard. The primary administrative issue was the initial failure to report his death to the coroner as a reportable death of a child in care, which was identified and corrected through departmental review processes.

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

Specialties

paediatricsintensive carerespiratory medicinepalliative careneurologyendocrinologyrehabilitation medicinephysiotherapy

Error types

system

Drugs involved

morphineoxygenantibioticshydrocortisone

Clinical conditions

cerebral palsyspastic quadriplegiaepilepsychronic respiratory diseaserecurrent pneumoniapulmonary collapsepseudomonas infectionparainfluenza infectiongastro-oesophageal refluxsevere osteopeniamicrocephalyblindnessdevelopmental delayasthma

Procedures

PEG tube feedingmechanical ventilationoxygen therapyintravenous antibiotics

Contributing factors

  • chronic respiratory disease
  • spastic quadriplegia cerebral palsy GMFCS V
  • epilepsy
  • recurrent respiratory infections
  • pseudomonas lung infection
  • parainfluenza virus infection
  • severe osteopenia
  • gastro-oesophageal reflux
  • blindness
  • microcephaly

Coroner's recommendations

  1. The coroner acknowledged that the Department of Communities had implemented new systems to ensure reportable deaths of children in care are reported to the coroner in a timely manner, and the coroner was satisfied these new processes are appropriate and should prevent similar failures in the future
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