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

3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and status epilepticus in a child with recent febrile illness and history of septo-optic dysplasia and panhypopituitarism

A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan for adrenal crisis requiring intramuscular hydrocortisone administration. His foster carer received only one-off training in 2018 on emergency hydrocortisone administration and was unable to successfully deliver the injection when the child became unresponsive at home. The coroner found the death resulted from natural causes but was deeply troubled by the lack of mandatory annual refresher training for carers managing children with medical conditions requiring emergency medication. The coroner found no evidence that earlier hydrocortisone administration would have changed the outcome, but made a recommendation for mandatory annual training for all such carers.