Coronial
WAhome

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

Deceased

Child AM

Demographics

3y, female

Date of death

2015-09-04

Finding date

2021-06-22

Cause of death

bronchopneumonia in an infant with obstructive sleep apnoea

AI-generated summary

A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complications including right heart hypertrophy, pulmonary hypertension, and sleep apnoea. She required CPAP/BiPAP support which compliance was poor. The coroner found the child had been appropriately investigated and treated across multiple hospitals with excellent multidisciplinary care. Key clinical lessons include: the need for robust outreach obesity services for remote regions; early recognition of severe paediatric obesity as a life-threatening condition; ensuring carers receive adequate training on airway support devices before discharge; and adequate communication of complex medical needs to foster carers. The Department of Communities, LWB, and CAHS have subsequently implemented improvements in training, remote monitoring of respiratory devices, and carer support.

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

Specialties

paediatricsrespiratory medicinecardiologyendocrinologyneurologyintensive careemergency medicinedieteticsphysiotherapy

Error types

communicationsystem

Clinical conditions

childhood obesityobstructive sleep apnoeaobesity-hypoventilation syndromepulmonary hypertensionright heart ventricular hypertrophybronchopneumoniaglobal developmental delayhyperinsulinemiahypercholesterolaemiaasthmaconstipationvitamin d deficiencyiron deficiencyatelectasis

Procedures

CPAP machine applicationbipap machine applicationadenotonsillectomysleep studychest CT scanMRI brain scancardiorespiratory monitoringcardiopulmonary resuscitation

Contributing factors

  • severe childhood obesity (36 kg at death)
  • obstructive sleep apnoea
  • poor compliance with CPAP/BiPAP machine use
  • global developmental delay
  • pulmonary hypertension
  • right heart ventricular hypertrophy
  • obesity-hypoventilation syndrome
  • respiratory tract infection (methicillin resistant Staphylococcus aureus, Haemophilus influenza, Enterovirus/Rhinovirus)
  • genetic and environmental factors contributing to obesity

Coroner's recommendations

  1. In order to address childhood obesity in remote and regional areas, the Western Australian government should consider introducing an outreach service for the Healthy Weight Service Clinic at Perth Children's Hospital
  2. In order for the program offered by the Healthy Weight Service Clinic to be culturally appropriate for Aboriginal families, the Western Australian government should consider reintroducing, on a permanent basis, the pilot program offered by the Healthy Weight Service Clinic from mid-2015 to early-2017
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