Inquest into the Death of ST

0y · Female·Pneumonia in an infant with surgically repaired congenital heart disease, prematurity and failure to thrive

A 9.5-month-old girl with complex medical history (prematurity at 29 weeks, congenital heart disease status post multiple repairs, necrotising enterocolitis with ileostomy, failure to thrive) died from acute pneumonia caused by rhinovirus, norovirus, and secondary Staphylococcus aureus infection. She was in out-of-home care with her grandparents at the time of death. The coroner found all medical care was appropriate, including hospital-based care at KEMH and PMH and community nursing via Hospital in the Home. While the HiTH nurse did not perform vital signs observations during a visit on 18 November when the child was unsettled, the coroner accepted this was not substandard practice. The death was from natural causes and essentially unpreventable given the child's significant medical vulnerabilities and the rapid progression of pneumonia.