Coronial
WAhospital

Inquest into the Death of Child SH

Deceased

Child SH

Demographics

5y, male

Date of death

2018-09-01

Finding date

2019-11-21

Cause of death

aspiration pneumonia with terminal palliative care, in a male child with complex medical co-morbidities including congenital myopathy and arthrogryposis

AI-generated summary

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respiratory infections, and required non-invasive ventilation support. During his final admission, a Do Not Resuscitate order was appropriately established after discussions with family and the treating team. The coroner commended Perth Children's Hospital's empathetic end-of-life care. However, the coroner identified that the Department of Communities missed an opportunity in March 2018 to provide intensive family support when the child's mother entered a relationship involving severe domestic violence. While more robust departmental intervention at that point might have improved family support and safety monitoring, the coroner found it unlikely to have changed the medical outcome.

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

Specialties

paediatricsrespiratory medicineintensive carepalliative care

Error types

system

Drugs involved

morphinemidazolamantibioticssaliva-reducing medications

Clinical conditions

congenital myopathyarthrogryposissevere kyphoscoliosisaspiration pneumoniarespiratory tract infectionlaryngomalaciaobstructive sleep apnoearespiratory failuredyspnoea

Procedures

percutaneous endoscopic gastrostomypercutaneous endoscopic jejunostomycontinuous positive airway pressurebi-level positive airway pressurenon-invasive ventilation

Contributing factors

  • congenital myopathy causing muscle weakness and unsafe swallowing
  • arthrogryposis with congenital joint contractures
  • severe kyphoscoliosis
  • recurrent aspiration pneumonia and respiratory tract infections
  • progressive respiratory failure
  • laryngomalacia and obstructive sleep apnoea
  • micrognathia and high arched palate

Coroner's recommendations

  1. The Department of Communities should provide more intensive family support to vulnerable families experiencing domestic violence, particularly when a carer is struggling with complex child health needs
  2. The Department should implement the Safe and Together model to improve child protection responses to family and domestic violence
  3. The Department should consider earlier referral to culturally appropriate services such as Wungenning Moort Aboriginal Corporation for intensive in-home support
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