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.
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
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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