Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associated lung and bowel disease while in parental care. Critical clinical lessons include: (1) his weight loss of 10% in final 10 days, indicating nutritional crisis, was not recognised as a medical emergency requiring admission; (2) growth charts were not consistently referenced to centiles despite available corrected-age charts; (3) nasogastric feeding was not offered despite poor oral intake; (4) discharge decisions on 28 February and 19 March 2019 relied on overly optimistic assessment of parents' capacity despite documented intellectual disabilities and communication difficulties; (5) treating clinicians were unaware of child safety concerns and multiple home-visit observations; (6) information sharing between hospital and child safety was inadequate; and (7) clinical escalation pathways for declining medically vulnerable infants were not activated.