Inquest into the death of Miss M

15y · Female·cardiac and respiratory arrest following pulmonary aspiration

Miss M, a 15-year-old Aboriginal girl with severe cerebral palsy and multiple medical complications, died from cardiac and respiratory arrest due to pulmonary aspiration. She had an Advance Care Directive (ACD) in place specifying no CPR, but resuscitation was initiated by carers and continued by ambulance and hospital staff, who were unaware of the ACD at the time. The coroner found the resuscitation appropriate given the acute presentation and potential for treatable airway obstruction. A key gap identified was that the ACD was not prominently placed in her medical file, making it difficult to locate during emergencies. The coroner noted that Katherine Hospital has since implemented education to ensure ACDs and care plans are kept at the front of files. Additionally, the coroner highlighted that medical staff failed to initially recognize this death as reportable due to the deceased's status as a child in care, emphasising the mandatory reporting requirement for such deaths.