Inquest into the Death of Michael Anderson

Contributing factors

• Administration of panadeine forte tablets (crushed or dissolved) containing paracetamol and codeine to a 9-day-old infant
• Extremely high serum concentrations of paracetamol (890mg/L) and codeine (3.72mg/L)
• Infant susceptibility to respiratory depression from opiates
• Failure to identify and investigate the perpetrator in a timely manner
• Systemic failures in police investigation and witness cooperation

Coroner's recommendations

1. WA Police Service treat the death of Michael Anderson as a murder inquiry that has not yet been finalised. The case should remain open until the circumstances of the poisoning have been adequately determined.
2. In the event of future suspicious deaths at KEMH, hospital management should assist police by providing access to information and files but not assume a role of obtaining witness statements. If hospital management does assist with obtaining witness statements, dates when witnesses have been contacted and the progress in respect of each witness statement should be monitored to ensure statements are obtained in a timely manner.
3. Australian Nursing Federation should review its practice in relation to advising nurses to ensure a clear distinction is drawn between advice as to law and suggestions as to policy; and make clear that nurses do not have to provide statements through the hospital and may provide statements directly to police or indirectly through the union or lawyers or not at all.