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

3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea

A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complications including right heart hypertrophy, pulmonary hypertension, and sleep apnoea. She required CPAP/BiPAP support which compliance was poor. The coroner found the child had been appropriately investigated and treated across multiple hospitals with excellent multidisciplinary care. Key clinical lessons include: the need for robust outreach obesity services for remote regions; early recognition of severe paediatric obesity as a life-threatening condition; ensuring carers receive adequate training on airway support devices before discharge; and adequate communication of complex medical needs to foster carers. The Department of Communities, LWB, and CAHS have subsequently implemented improvements in training, remote monitoring of respiratory devices, and carer support.