Inquest into the death of Jessica Poulson

CITATION: Inquest into the death of Jessica Agnes Poulson

[2018] NTLC 027 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0030/2017 DELIVERED ON: 26 November 2018 DELIVERED AT: Darwin HEARING DATE(s): 8 November 2018 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Death in care, 17 days old baby, congenital heart defect, expected death, appropriate care and treatment

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Territory Families: Gabby Brown Judgment category classification: A Judgement ID number: [2018] NTLC 027 Number of paragraphs: 25 Number of pages: 5

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0030/2017 In the matter of an Inquest into the death of

JESSICA AGNES POULSON ON 28 APRIL 2017 AT ALICE SPRINGS HOSPITAL FINDINGS Judge Greg Cavanagh Introduction

1. Jessica Agnes Poulson was born on 11 April 2017 to Rosemary Beasley and Anthony Poulson. She died 17 days later on 28 April 2017. Her death was expected. She was born with a rare congenital defect of the heart: hypoplastic left heart syndrome.

2. This is a mandatory inquest because during the 17 days of her life she was in the care of the CEO Territory Families. Her death was thus a death in care.

3. The defect of her heart was diagnosed when her mother was 18 weeks into the pregnancy. The condition is fatal if not treated surgically within a few days after birth. The surgery was such that it could not have been undertaken in the Northern Territory. The mother would have had to give birth in a Melbourne or Sydney Hospital.

4. The Head of the Paediatric Division at the Alice Springs Hospital wrote of the potential future of Jessica in these terms: “Even if the baby survives the initial surgery required in the first few days of life, the child will require ongoing medication and further surgery throughout her life. The initial stay in Melbourne will be for approximately 5 – 6 months … The child’s cardiac condition is such that she may not be able to ever live in Tennant Creek and may not

even be able to return to Alice Springs, due to lack of local specialist cardiology care. Even if the first couple of surgical procedures are successful, the baby will remain cyanotic and under specialist cardiac care. A second lot of cardiac surgery will be required at approximately 4 -5 years of age. Eventually the child may require a complete heart transplant … In addition to the cardiac issue, there are still major risks of intellectual disability and psychiatric issues.

Hypoplastic left heart syndrome has been independently associated with poorer neurological outcomes.”1

5. It was said that the preference of the paediatric consultants, specialist paediatric cardiologist and obstetrician was that “it would probably be best to allow the baby to pass away in the arms of its mother”. The view of the extended family was that if it was “God’s will” that the child should die, the family would accept that.

6. The father was approached to see if he was willing to make a decision in relation to the medical care of Jessica but he indicated that he thought that was a matter for the mother.

7. The complication was that it was believed that the mother did not have the capacity to make a decision. That led to an Adult Guardianship Order in relation to the mother and Territory Families organised to seek an order for the care of Jessica when she was born.

8. Jessica was born by caesarean section at 37 weeks and one day on 11 April 2017 at 4.19pm. She had a birth weight of 2700 grams, a length of 48 centimetres and a head circumference of 32.5 centimetres. Her Apgar scores were 8 at 1 minute, 9 at 5 minutes and 9 at 10 minutes. Jessica was admitted to the Special Care Nursery for palliation.

9. Shortly after her birth the CEO of Territory Families applied for and was granted parental responsibility of Jessica for two months.

1 Letter from Dr Debbie Fearon dated 3 April 2017

10. Her mother remained an inpatient until 22 April 2017. She was then discharged to remain as a boarder while ever Jessica remained in Hospital.

11. Contact was had with her father about whether he wanted to see Jessica. At the time he was at the Barkly Work Camp. However he preferred to leave the support of Jessica to her mother and her mother’s extended family.

12. Jessica’s mother had Jessica with her on a regular basis while in the Hospital. On 13 April 2017 at 3.35pm her mother asked that the Chaplain pray for Jessica and baptise her. That was done.

13. Jessica remained relatively stable and settled until 18 April 2017. She was noted to become unsettled. Her heart rate and breathing increased and she took on a “dusky” appearance and suffered intermittent head bobbing.

14. She had been treated with oral analgesia when unsettled. However on 19 April 2017 her deterioration led to discussion about the commencement of intravenous morphine.

15. Her mother had her for about two and a half hours that morning and spoke of her wish to take Jessica back to Tennant Creek on Friday (21 April 2017).

That afternoon at 2.00pm Jessica was given her first dose of morphine. She settled well.

16. Thereafter she seemed to improve. She spent most of the morning on 21 April 2017 with her mother in her room. She was noted to be well-perfused.

She wasn’t distressed and was not needing morphine.

17. At 2.00pm on 23 April 2017 her mother indicated that the following day she would be taking Jessica back to Tennant Creek. She refused to accept that Jessica was dying. She continued to insist that Jessica was now well.

Jessica’s mother’s behaviour became more and more challenging. Much of that seemed to relate to an inability to grasp that Jessica was inevitably going to die in the shorter term.

18. At a multidisciplinary meeting on 26 April 2017 it was thought that Jessica might be adjusting to her condition better than expected and she might live for a number of months.

19. The following day (27 April 2017) due to the insistence by Jessica’s mother that she was taking Jessica back to Tennant Creek she was not permitted to come onto the ward without the agreement of Territory Families staff.

20. At 6.00am on 28 April 2017 it was noted that overnight there was significant effort needed by Jessica to breath and her respiratory rate was elevated.

When checked by the paediatrician that morning it was noted that when she cried she became cyanotic, pale and sweaty. Femoral pulses were unable to be felt. It was thought that the final deterioration had commenced.

21. At 10.30am her mother visited. Jessica began to cry and appeared in distress. She was given morphine. She settled. However it was noted that her colour was not good.

22. From 2.30pm her breathing became shallow and irregular and her heart began to slow. The notes say that she was peaceful. Her death was confirmed at 3.15pm.

23. At the request of family, photos were taken and footprints and handprints placed in a “Memorial Booklet” along with a lock of hair.

24. Jessica’s death was expected even before she was born. The care and treatment of her was of a high standard. The only issues experienced were in managing the expectations and understanding of Jessica’s mother. The evidence indicates however that a great deal of effort was put into communication and management with the mother and her family, by those at the hospital, the Office of the Public Guardian and Territory Families.

25. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased was Jessica Agnes Poulson born on 11 April 2017, Alice Springs, Northern Territory.

(ii) The time of death was 3.15pm on 28 April 2017. The place of death was Alice Springs Hospital, Alice Springs in the Northern Territory.

(iii) The cause of death was hypoplastic heart syndrome.

(iv) The particulars required to register the death:

1. The deceased was Jessica Agnes Poulson.

2. The deceased was of Aboriginal descent.

3. The deceased was an infant.

4. The death was reported to the Coroner by Alice Springs Hospital.

5. The cause of death was confirmed by Dr Debbie Fearon.

6. The deceased’s mother was Rosemary Beasley and her father was Anthony Poulson.

Dated 26 day of November 2018.

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GREG CAVANAGH TERRITORY CORONER