Coronial
WAhome

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

Deceased

Child ML

Demographics

7y, female

Coroner

Coroner Jenkin

Date of death

2019-02-24

Finding date

2023-11-10

Cause of death

Pneumonia complicating a viral respiratory illness with acute combined drug effect in a young girl with cerebral palsy, recurrent aspiration, and chronic seizure disorder

AI-generated summary

Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At the time of death, she was in departmental care with supervised access to her mother Ms A. Toxicology revealed high codeine and morphine levels, despite Child ML not being prescribed codeine. No evidence identified who administered codeine. Critical failures included: inadequate training for foster carer Ms B and safety network members Mr and Mrs C; insufficient analysis of feeding bags/tubes by police (later discarded); and departmental oversights in support provision and safety planning. The coroner found standard of supervision and care woefully inadequate, particularly during unsupervised access visits.

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

Specialties

paediatricsrespiratory medicineneurologygastroenterologytoxicologyforensic medicine

Error types

medicationsystemsupervisiondelay

Drugs involved

codeineparacetamolmorphineclonazepamdiazepamoxazepamtemazepamgabapentinbaclofensodium valproateibuprofen

Clinical conditions

spastic quadriplegiacerebral palsychronic lung diseaseseizure disorderaspirationpneumoniahypernatremiamalnutritiondehydrationrespiratory failuretwin-to-twin transfusion syndrome

Procedures

PEJ tube feedingpost-mortem examinationtoxicological analysis

Contributing factors

  • High levels of codeine and morphine in system (overdose)
  • High levels of gabapentin
  • Benzodiazepines (clonazepam, diazepam) with synergistic respiratory depressant effect
  • Severe underlying respiratory compromise from cerebral palsy and chronic aspiration
  • Viral respiratory infection (Rhinovirus)
  • Bacterial infection (Klebsiella pneumoniae, Staphylococcus aureus)
  • Inadequate supervision during access visit
  • Inadequate training of safety network members
  • Inadequate departmental support and safety planning

Coroner's recommendations

  1. Western Australian Police Force and PathWest develop a protocol or procedure to deal with the analysis of items (including medication, syringes, feeding bags, tubes etc) seized at the scene of the death of a vulnerable person, including a child, to ensure all relevant items are seized and analysed to determine their relevance to the death
  2. Department of Communities consider offering, at no cost, first aid training to the carers of children with complex medical needs, and to persons who provide support and supervision for such children during access visits with the child's significant others
  3. Department of Communities strengthen the oversight process for members of the safety network of children in care who have complex medical needs, and ensure that those persons are provided with education and information about the child's care needs
Full text
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Source and disclaimer

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