Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex medical co-morbidities including congenital myopathy and arthrogryposis

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respiratory infections, and required non-invasive ventilation support. During his final admission, a Do Not Resuscitate order was appropriately established after discussions with family and the treating team. The coroner commended Perth Children's Hospital's empathetic end-of-life care. However, the coroner identified that the Department of Communities missed an opportunity in March 2018 to provide intensive family support when the child's mother entered a relationship involving severe domestic violence. While more robust departmental intervention at that point might have improved family support and safety monitoring, the coroner found it unlikely to have changed the medical outcome.