Inquest into the Death of David Kalunda FLYNN
Deceased
David Kalunda Flynn
Demographics
2y, male
Date of death
2021-12-07
Finding date
2025-08-22
Cause of death
Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
AI-generated summary
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despite using an opioid that causes vomiting; no continuous monitoring of oxygen levels or vital signs; and discharge from the clinic while still deeply asleep, less than 1.5 hours after the injection. Evidence suggests the morphine dose was higher than intended. David collapsed at home about 4 hours later and was found without a pulse at 6:30pm. Despite resuscitation, he died from opioid overdose. Experts agreed that if David had been properly monitored at the clinic, his dangerous drowsiness would have been detected and an antidote could have been given, likely saving his life. The case highlights the need for general practitioners performing sedation to follow national guidelines on monitoring and safe discharge, especially for young children.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to implement fasting protocols before sedation despite using opioid emetic agent
- No continuous monitoring of oxygen saturation, heart rate, blood pressure, respiratory rate, or capnography
- Discharge from clinic while deeply sedated, less than 1.5 hours post-morphine injection
- Suboptimal choice of morphine as sedating agent (slow onset, long duration, unreliable subcutaneous route)
- High-concentration morphine solution (30mg/ml) in small syringe (1ml) creating large margin for dosing error
- Likely opioid overdose (evidence suggests administered dose exceeded 3mg intended dose)
- Failure to review ultrasound result prior to procedure showing undescended testicles
- Inadequate informed consent regarding sedation-specific risks
- Lack of pre-calculated naloxone doses for emergency use
- Non-compliance with Australian and New Zealand College of Anaesthetists PG09(G) procedural sedation guidelines
Coroner's recommendations
- Forward this finding to the Royal Australian College of General Practitioners (RACGP) Western Australia and ask them to consider circulating it to their members along with a link to the Australian and New Zealand College of Anaesthetists PG09(G) Guideline on Procedural Sedation 2023
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