Deceased
David Kalunda FLYNN
Demographics
2y, male
Coroner
Coroner Hartley
Date of death
2021-12-07
Finding date
2025-07-31
Cause of death
cardiorespiratory arrest in a young child with opioid (morphine) toxicity
AI-generated summary
David Flynn, a healthy 2 year 8 month old boy, died from cardiorespiratory arrest due to opioid (morphine) toxicity following an elective circumcision procedure performed under sedation in a general practice setting on 7 December 2021. The procedure was performed by Dr H. at Gosnells Medical Clinic using subcutaneous morphine (intended dose 3mg) as the sedating agent. Critical failures included: inadequate informed consent regarding sedation risks, lack of peri-operative monitoring (no pulse oximetry, capnography, or vital sign recording), discharge of a deeply sedated child less than 90 minutes after morphine injection (well before peak effect at 50-90 minutes), failure to observe fasting protocols prior to sedation, and failure to review an ultrasound showing undescended testicles which might have changed management decisions. Expert evidence confirmed that with appropriate monitoring and adherence to discharge criteria, David's deterioration would have been detected and opioid reversal with naloxone could have been administered, likely preventing his death. The coroner found Dr H. administered higher than intended morphine dosage, made poor choices regarding morphine formulation and syringe size (increasing dosing error risk), and failed to follow Australian and New Zealand College of Anaesthetists guidelines for procedural sedation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
13y · Male·Epileptic seizure with aspiration
Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…
49y · Male·ligature compression of the neck (hanging)
Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.