Finding into death of H B

8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cachexia

HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Between January and August 2013, her weight dropped from ~20kg to 12kg—a loss of 8kg over 7 months. Analysis of delivered formula showed only ~152 litres received versus ~280 litres prescribed, meaning she received approximately 50% of her nutritional needs. Her mother failed to attend any medical appointments for HB from January 2013 onward, missed multiple paediatric, dietetic and neurological reviews, and did not seek medical attention despite obvious severe weight loss. Child Protection received multiple reports but made flawed intake decisions, underestimating HB's vulnerability and disability needs, and placing excessive weight on the mother's assertions. ChildFIRST intake assessments were severely delayed (>2 months with no substantive contact), representing a critical missed opportunity for intervention. The death was preventable had adequate nutrition been provided, medical care continued, and the child protection system responded more robustly to cumulative indicators of neglect.