Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. His GP, Dr A., diagnosed concussion and sent him home. When Dwayne vomited—abnormal for him—his mother took him to Kalgoorlie Regional Hospital, where resident intern Dr P. also diagnosed concussion. The following morning, Dr W. arranged a CT scan, but it could not be completed without sedation. Dr A. delayed the scan until 13 April, stating Dwayne appeared stable. When the CT scan was finally performed, it revealed a massive epidural haematoma. Emergency surgery was attempted but Dwayne died from cerebral coning. The coroner found the critical failure was delayed CT imaging. Early neurological imaging on 11 April would likely have changed the outcome. The case highlights the challenge of assessing deeply disabled children and the importance of using diagnostic imaging when clinical assessment is difficult, particularly in regional settings with limited specialist support.