Inquest into the Death of Child B (Name Subject to Suppression Order)
Deceased
Child B
Demographics
3y, male
Date of death
2020-12-08
Finding date
2022-12-08
Cause of death
Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and status epilepticus in a child with recent febrile illness and history of septo-optic dysplasia and panhypopituitarism
AI-generated summary
A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan for adrenal crisis requiring intramuscular hydrocortisone administration. His foster carer received only one-off training in 2018 on emergency hydrocortisone administration and was unable to successfully deliver the injection when the child became unresponsive at home. The coroner found the death resulted from natural causes but was deeply troubled by the lack of mandatory annual refresher training for carers managing children with medical conditions requiring emergency medication. The coroner found no evidence that earlier hydrocortisone administration would have changed the outcome, but made a recommendation for mandatory annual training for all such carers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Adrenal crisis triggered by acute febrile illness
- Inability of foster carer to administer emergency hydrocortisone injection due to lack of recent training and panicked state
- Lack of mandatory annual refresher training for emergency medication administration
- Rapid and unpredictable clinical deterioration in adrenal insufficiency
Coroner's recommendations
- The Department of Communities should examine the feasibility of providing mandatory annual training for carers who look after children with medical conditions that may require the administration of emergency medication. The Department should also consider how health navigators could assist in facilitating this crucial training. Training should be documented and preferably delivered using realistic scenarios, by analogy with CPR training which requires annual refresher competency.
- Standard ambulances should be reviewed regarding whether they should carry hydrocortisone for adrenal crises, noting that Clinical Support Paramedic vehicles carried hydrocortisone following introduction of SJA Clinical Practice Guideline in 2021.
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