Coroner's Finding: Master T

3y · Male·Hypoxic brain injury secondary to cardiorespiratory arrest, possibly secondary to sepsis; likely aspiration pneumonitis

Master T, aged 3 years, died from hypoxic brain injury secondary to cardiorespiratory arrest, likely due to aspiration pneumonitis. He had severe congenital abnormalities including holoprosencephaly with VP shunt, anal atresia, oesophageal atresia, and developmental delay. He was admitted to hospital on 3 August 2019 with a 2-3 day history of unwellness, vomiting, and feed refusal. After appropriate assessment including CT brain and blood tests, he was discharged. That night he aspirated while sleeping and suffered cardiorespiratory arrest. The coroner found the assessment and discharge decision appropriate, the hospital care attentive and competent, and his foster carer's management exemplary. No clinical errors or preventable factors were identified.