Inquest into the Death of PT (Name Subject to Suppression Order)
Deceased
PT
Demographics
5y, female
Date of death
2016-01-27
Finding date
2020-09-23
Cause of death
aspiration of vomit with microscopic early pneumonia, in a child with a history of cerebral palsy and epilepsy
AI-generated summary
A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants is a 'red flag' requiring specialist paediatric assessment; GPs must directly communicate with child protection services when concerns arise and should not offer reassurance letters based on incomplete information; thrombocytosis with falling haemoglobin suggests internal bleeding and warrants specialist investigation; child protection workers should directly contact assessing clinicians rather than relying on parents to relay concerns. The coroner identified failures in communication between GPs Dr S. and Dr M. and child protection services, where both GPs wrote letters minimising concerns about suspicious injuries in a vulnerable child. High Risk Infant Policy introduced in 2018 now mandates same-day paediatric assessment of any injuries in non-mobile infants under two years.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- non-accidental head injuries at two months old resulting in severe cerebral palsy with poor head control and swallowing dysfunction
- seizure disorder
- gastro-oesophageal reflux disease secondary to cerebral palsy
- failure to recognize bruising in non-ambulant infant as sentinel injury in 2011
- GP letter providing false reassurance that thrombocytosis explained bruising, delaying investigation of abuse
- inadequate direct communication between GP and child protection services prior to assessment
- misinterpretation of thrombocytosis as primary blood disorder rather than response to trauma
Coroner's recommendations
- Undertaking of a regulatory impact review by Western Australian Government
- Amendment to Children and Community Services Act 2004 (WA) to include a duty to report any injuries in a non-ambulant child, in similar terms to sexual abuse reporting requirements
- Extension of mandatory training program jointly provided by Department of Communities and Department of Health to include education on duty to report injuries in non-ambulant children
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