Coronial
WAhome

Inquest into the Death of Baby E (Name Subject to Suppression Order)

Deceased

Baby E

Demographics

0y, male

Coroner

Coroner Urquhart

Date of death

2020-02-01

Finding date

2021-08-26

Cause of death

Complications of VATER syndrome and sacrococcygeal teratoma

AI-generated summary

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in Perth Children's Hospital for over 5 months with multiple complex medical conditions requiring multidisciplinary surgical and medical management. Following deterioration and development of end-stage renal failure with a progressively enlarging spinal tumour, a compassionate decision was made to transition to palliative care in December 2019. Baby E was discharged to his grandmother's care just before Christmas 2019 and died at home on 1 February 2020. The coroner found the medical care at all hospitals was of high standard and the Department's involvement in his care was appropriate. No preventable factors were identified.

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

Specialties

neonatologynephrologypaediatric surgeryneurosurgeryrespiratory medicinecardiologyhaematologyinfectious diseasespalliative careoncology

Clinical conditions

VATER syndromesacrococcygeal teratomaimperforate anusabsent left kidneydysplastic right kidneychronic kidney disease stage 5hypertensive nephropathyrenal osteodystrophychronic lung diseaserecurrent aspirationvertebral anomaliesneonatal hypertensionpulmonary haemorrhagepatent ductus arteriosusseizures

Procedures

intubationventilationcolostomybowel surgerykidney surgerylong line insertion

Contributing factors

  • End-stage chronic kidney disease stage 5
  • Sacrococcygeal teratoma with spinal cord compression
  • Vertebral abnormalities including scoliosis and hemivertebrae
  • Imperforate anus requiring colostomy
  • Unilateral renal agenesis and dysplasia of right kidney
  • Chronic lung disease with recurrent aspiration
  • Renal osteodystrophy
  • Renal-induced hypertension with left ventricular hypertrophy
  • Maternal illicit drug use during pregnancy

Coroner's recommendations

  1. The coroner did not make specific recommendations but noted the Department's response providing Chapter 3.2.12 (Termination of life support and palliative care) from the Department's Casework Practice Manual, which had been amended on 16 August 2021 to include guidance on palliative and end-of-life care for children in the CEO's responsibility.
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