Inquest into the Death of Child MML

Contributing factors

• severe neurological impairment from traumatic brain injury sustained in infancy
• inability to coordinate swallowing and coughing due to brain dysfunction
• deteriorating respiratory function over time
• deteriorating gastrointestinal function requiring long-term enteral feeding
• chronic seizures requiring multiple medications
• quadriplegic cerebral palsy preventing self-care and movement
• aspiration risk from neurological impairment
• chronic constipation progressing to bowel necrosis

Coroner's recommendations

1. Department and Child and Adolescent Health Service to continue developing shared understanding of end-of-life care planning processes for children in care, including clarity on Goals of Patient Care forms and decision-making authority
2. Department to implement executive-level oversight of children in care on palliative care pathway through regular briefing of executive team status, enabling timely high-level decision-making
3. Ensure after-hours availability of Department executive-level decision makers for urgent Goals of Patient Care decisions
4. Develop clear policy guidance for frontline staff regarding roles, responsibilities, and escalation procedures for end-of-life care decision-making
5. Ensure medical clinicians lead all family discussions regarding end-of-life care planning and palliative care, given the complexity and emotional nature of these conversations