Demographics
0y, male
Coroner
Acting State Coroner Linton
Date of death
2022-09-04
Finding date
2025-11-05
Cause of death
Streptococcus pyogenes and parechovirus infection
AI-generated summary
An eight-month-old boy in state care died from Streptococcus pyogenes and parechovirus infection. He presented to hospital twice before death with fever and ear infection symptoms. On first presentation (2 September), he was assessed as having likely viral otitis media with normal observations; discharge was appropriate. On second presentation (4 September morning), observations were mildly abnormal but improved with paracetamol; oral antibiotics were started. He was discharged home with safety-netting for return if worse. He deteriorated rapidly that evening and presented in cardiac arrest, resuscitation efforts unsuccessful. The coroner found no clinical failings: sepsis recognition is genuinely difficult in young children who may compensate well until sudden collapse; the presentations lacked fever and classic septic signs; the prescribed antibiotic was appropriate; and imaging/transfer were not indicated at the time. The rapid deterioration characteristic of invasive Group A Strep in young infants occurred between discharge and readmission.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
FILE NO/S : CORC 28 of 2022
Catchwords:
Nil
Legislation:
Nil
Counsel Appearing:
Ms S Markham assisted the Coroner Ms K Ellson (SSO) appeared on behalf of the WA Country Health Service and the Department of Communities
Case(s) referred to in decision(s):
Nil
Page |
Coroners Act 1996 (Section 26(1))
I, Sarah Helen Linton, Acting State Coroner, having investigated the death of Child WK (name suppressed) with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth on 19 March 2025, find that the identity of the deceased person was Child WK and that death occurred on 4 September 2022 at Carnarvon Hospital, 20 Cleaver Street, Carnarvon from Streptococcus pyogenes and parechovirus infection in the following circumstances:
INTRODUCTION. .cccccccesseseeneesreeveesersersrnerseseesnessessecsessessessestessarsnestensenteegesneed 3 DECISION TO TAKE CHILD WK INTO CARE... ccccccsessescrsteterecreseseneaseneneeesi 3 FIRST PRESENTATION ~ 2 SEPTEMBER 202.2 .cccccscsssssccnssessssscnessseennnceneenens 6 SECOND PRESENTATION -— 4 SEPTEMBER 2022 .cccscsssecssesessessssrserereeee 8 THIRD AND LAST PRESENTATION — 4 SEPTEMBER 2022 .. ww 12 WACHS CLINICAL INCIDENT INVESTIGATION. ..ccccsscesseveesesteseetesesneerenenes 15 COMMENTS ON MEDICAL CARE... cece eeessesceeeeneeseeseeacssneneeseeaneesecsensranees 19 DEPARTMENT OF COMMUNITIES’ INVOLVEMENT .... ve
CONCLUSION viccccscscscesesssssssecsessersessesasssceeesessssnssneseeneenessesnesarensereaseeseeseeees 22
Suppression of the deceased’s name, the deceased’s siblings names and the names of any other family members from
publication and any evidence likely to lead to their identification.
The deceased is to be referred to as Child WK.
Child WK was an eight month old infant boy who died suddenly on 4 September 2022 from a combined bacterial and viral infection. His mother had been concerned that he was unwell and had sought medical attention twice at Carnarvon Hospital prior to his death, including on the morning he died. Child WK had been prescribed antibiotics, which his mother had given him at home as directed, but his condition continued to deteriorate at home. He was brought back to the hospital by his mother again that night, but sadly it was too late to save him.
At the time of his death, Child WK was a child under the care of the CEO of the Department of Communities (Communities). Therefore, he came within the definition of a ‘person held in care’ under the Coroners Act 1996 (WA) and a coronial inquest into his death is mandatory.
held an inquest on 19 March 2025. As Child WK was a child in care, | am required to comment on the quality of the treatment, supervision and care given to Child WK while in care, prior to his death, so evidence was led to assist me in considering all of these aspects of his care from the perspective of Commnunities.! However, noting Child WK died from an infection that was potentially treatable, and he had been seen in hospital more than once prior to his death, a further focus of the evidence was his medical care prior to his death and whether the medical care was reasonable in all the circumstances.
Significant documentary evidence was tendered and three witnesses were called to give oral evidence:
e Dr Geert Dijkwel - the General Practitioner who treated Child WK at Carnarvon Hospital immediately prior to his death;
. Dr Andrew Savery ~ a Consultant Paediatrician who reviewed the medical care Dr Dijkwel provided to Child WK prior to his death; and
® Ms Rochelle Binks — the Executive Director for Child Protection and lamily Support at the Department of Communities.
Child WK’s mother, Ms WJ, attended the inquest hearing remotely from the Carnarvon Courthouse. WJ understandably also had some questions of her own about the medical care provided to her son. I have considered her questions and tried to answer them from the evidence before me in the process of drafling this finding.
Child WK was one of four children to his mother, WJ. He was his mother’s youngest child at the time of his death and the only one living with his mother at that time. All three other children were also in the care of Communities, but unlike Child WK, they were living with other relatives at the relevant time.” The primary
' Sections 22(1}(a) and 25(3) Coroners Act 1996 (WA); Section 3 Children and Community Services Act
? Exhibit 1, Tab 12.
reason for child protection involvement with Child WK and his siblings appears to have been due to concerns about his mother’s drug and alcohol use, which had led to mental health issues and affected her capacity to parent safely.
In 2021, WJ was struggling with methylamphetamine addiction and on 11 August 2021 she presented to hospital with drug-induced psychosis. She was still caring for her youngest child at that time, Child MWA. WJ was held in hospital as an involuntary patient under the Mental Health Act 2014 (WA) and Child MWA was taken into the care of the CEO of Communities. Child MWA was placed initially with the child’s maternal grandmother with regular contact with Child MWA’s biological father, MG. While in hospital, WJ found out she was 17 weeks pregnant with Child WK. She stopped using drugs after becoming awate she was pregnant?
Communities was also notified of Child WK’s impending birth, which led to Pre-Birth Planning being initiated by Communities’ staff. Her estimated due date was 10 February 2022. During the Pre-Birth Planning process, concerns were identified about WJ’s ongoing drug and alcohol use, as well as her mental health issues and limited accommodation and support network. WJ had transitioned to voluntary patient status after a period, but on 14 January 2022, prior to Child WK’s birth, his mother’s mental health deteriorated again and she transitioned back to being an involuntary patient under the Mental Health Act 2014 (WA). She was flown from Carnarvon to Perth for psychiatric assessment and treatment. Based upon the information available to Communities at that time, it was determined there was substantiated likelihood of harm to the baby from neglect. Accordingly, a decision was made on 27 January 2022 to bring the newborn baby into Provisional Care and Protection as soon as practicable after birth.*
Child WK was born on 28 January 2022 via pre-planned caesarean section at King Edward Memorial Hospital in Perth. Child WK’s biological father was not known by Communities at the time of his birth. WJ later provided information in relation to the identity of Child WK’s father, but no contact was ever able to be made with him by Communities and he was not recorded on Child WK’s birth certificate.
Therefore, all contact between Communities and Child WK’s family was with maternal family members.>
Child WK was taken into care and placed by Communities with general foster carers a few days after his birth. Communities’ staff explored options for a family placement over the following month and Child WK was then placed with his maternal grandmother on 3 March 2022 along with Child MWA, with the long term plan to work towards reunification with their mother.®
WI went to Geraldton to be near Child WK and her other children. Communities were advised by WJ and her mother that she had begun living at the home with her
3 Exhibit 1, Tab 8 and Tab 12.
4 Exhibit 1, Tab 12 and Tab 13.
5 Exhibit 1, Tab 13.
© Exhibit 1, Tab 13.
mother and children and an interim safety plan was agreed to ensure that the safety of Child WK and the other children was prioritised.”
Communities had been assisting WJ to obtain a placement at Cyrenian House for drug rehabilitation and a safety plan was developed so that Child WK could go with her.’
On 12 April 2022, WJ was admitted to Cyrenian House to receive therapeutic support for substance addiction. Communities consented to Child WK being admitted with her. It was planned that mother and baby would remain living together at the service for at least six months (until October 2022) and up to 12 months.
Child WK was monitored by a doctor during this period and he received his immunisations as per the usual schedule. He seems to have been generally well during this period, other than a likely bout of COVID-19 in early June 2022 and a short bout of diarrhoea with an unknown cause.”
On 6 May 2022, WJ requested that Child MWA also be permitted to reside with her at the program. Whilst this was being considered, Child MWA’s father advised Communities that he had resumed a relationship with WJ. He had been gradually taking over as primary caregiver for Child MWA and was considered a ‘safe parent’ at this time. He sought permission to bring Child MWA to Cyrenian House for a visit, but this was unable to be arranged due to COVID-19 outbreaks, !”
After four and a half months, WJ decided she wanted to leave the program early as she missed her partner and other children. Communities were notified and they developed a travel safety plan for MG to collect WJ and Child WK from Cyrenian House and transport them to Camarvon. They left Cyrenian House on 19 August 2022. Although it was a little earlier than planned, their departure occurred with the knowledge of Communities staff, who developed a safety plan to support Child WK remaining in the care of his mother, with MG and Child MWA, after she left the rehabilitation facility. WJ returned to Carnarvon with her baby, partner and second youngest child, where they began living with a friend of MG."!
WJ’s partner believed WJ was doing well after leaving the rehabilitation programme and returning to Carnarvon. He noted Child WK was a little bit grizzly at times duc to teething, but otherwise seemed to be a happy and healthy child.!?
Communities remained in contact with the young family for the first two weeks and they observed positive interactions between Child WK, his mother and her partner.
They were last seen on 30 August 2022 at the Carnarvon Communities office.
Everything seemed to be going well and no concerns were raised. WJ was given a
7 Exhibit 1, Tab 2.1, Tab 12 and Tab 13.
5 lixhibit 1, Tab 13.
° Exhibit 1, Tab 2.1, Tab 12, Tab 13 and Tab 18.
'0 Exhibit 1, Tab 13.
"Exhibit 1, Tab 2.1, Tab 12 and Tab 13.
'2 Yexhibit 1, Tab 2.1.
a
22,
letter of support for Communities’ Housing division as they were hoping to be able to get their own place to live. Communities staff did not have any further contact with the family prior to Child WK’s sudden death.”
Prior to his death, Child WK was living with his mother, her partner GM and his half-siblng MWA in Carnarvon, in the home of some friends, and he appeared to be meeting his milestones and was generally well cared for and well loved.
Medical records indicate WJ had generally been a well child since birth. He was not prescribed any regular medications and had undergone all of his suggested immunisations."4
On about 30 or 31 August 2022, WJ became worried about Child WE as he was having high fevers. She bought a thermometer and used it to check his temperature, which read 38.4°C. WJ gave him children’s Panadol and Nurofen and let him rest, but Child WK continued to record high temperatures. WJ told police she called the government health advice service, Healthdirect, to discuss her concerns and she was old to continue giving her baby Panadol and Nurofen, as she had already been doing, and to call back if he got worse.!°
The following day, Child WK was still unwell, had an abnormal bowel motion and wouldn’t stop crying. His mother called Healthdirect again and after explaining that he was not improving, she was told to take Child WK immediately to hospital for medical review. WJ called her partner, who immediately came over and drove WJ and Child WK to the hospital.'®
They presented to Carnarvon Hospital Emergency Department at 8.18 am on 2 September 2022. Child WK’s observations were taken at 8.30 am and all his observations were within acceptable ranges. At primary assessment, it was noted that Child WK’s airway was patent and his breathing, colour, pulse and circulation/skin were all unremarkable. The triage history taken from his mother recorded that he had been crying intermittently overnight, his abdomen had been reportedly quite hard, and he had had a very large bowel movement the previous day and another bowel movement that day. He was eating and drinking as normal and alert but crying. It was indicated that he was up to date with his regular childhood vaccination schedule."
Child WK was allocated a triage category score of 3 (indicating he should be seen within 30 minutes) and was given ibuprofen at 8.45 am. He was seen by GP Dr Dijkwel, who was on shift in the ED, shortly after!® Dr Dijkwel had been working in Carnarvon as a doctor since 2006 and he knew Child WK’s mother from
8 Exhibit 1, Tab 13.
4 Exhibit 1, Tab 13.
S Exhibit 1, Tab 8.
6 Exhibit 1, Tab 8.
Exhibit 1, Tab 15 - Triage Notes 2.9.2022.
8 Exhibit t, Tab 15 — Triage Notes 2.9.2022.
24,
25,
previous care. He was aware from previous interactions that WJ had issues with illicit substance use and mental health issues but on this day she seemed well and did not appear to be under the influence of any substances. Dr Dijkwel had not treated Child WK previously. Child WK was seven months old at this time and at first glance he appeared to be a well-fed baby of good weight for his age. He also appeared clean and well looked after. Observing the two together, Dr Dijkwel thought WJ seemed to be focused and engaged and “doing the things that a good mother does,”!° including seeking help for her unwell child.”
Dr Dijkwel was given a history that Child WK had been crying, likely due to abdominal pain. He was reported to have settled after being given ibuprofen and had no fever and his chest appeared clear. Dr Dijkwel recalled that Child WK presented as unsettled initially, but his vital observations (including temperature, heart rate and respiratory tate) were all normal. Dr Dijkwel performed a physical examination and the only abnormal finding was that both his eardrums were red. He also had a slight cough. Dr Dijkwel formed the impression that Child WE had un uncomplicated inner ear infection (otitis media), which is a common presentation in small children. The treatment plan was for Child WK to be given analgesia (Panadol and Nurofen).
Dr Dijkwel did not prescribe antibiotics at this time as he thought Child WK had a simple viral upper respiratory tract infection affecting his ears, which was of recent onset. Dr Dijkwel explained that antibiotics are not indicated if a doctor suspects a viral infection, and guidelines also recommend waiting for 48 hours before starting antibiotics.2!
Dr Dijkwel gave an instruction that Child WK should be brought back for review the following day if he was very unsettled or reviewed in two days’ time if he was no better. Dr Dijkwel explained at the inquest that he would not ask every child to come back for review, but in this case, he considered the social situation was different as he knew WIJ’s other children were in care, and he felt WJ needed more support. He gave evidence that he was not concerned for Child WK’s health at that time but thought it would be a good idea to see him again in 48 hours for review, just in case.
With that plan in place, Child WK left the ED with his mother at about 10.15 am.”
Dr Dijkwel noted that Child WK had been under direct visual observation in one of the ED beds closest to the nursing station for over 1 hour 45 minutes before he went home and following the administration of ibuprofen he had settled and appeared happy, playful and interactive when observed by the nursing and medical staff.”
27, Child WK’s mother later told police she was okay with going home at the time as she had seen an improvement in her son during the hour or so he was in the hospital, although he did start to become unsettled again shortly before they left the ED. She reported to police that after they returned home, Child WK was eating his food and
eT,
20 T 6 - 7; Exhibit 1, Tab 20.1.
2379, 16,
227 5 - 9; Exhibit 1, Tab 15 — Triage Notes 2.9.2022 and Tab 20.1.
3 Exhibit 1, Tab 20.1.
30,
his need for Nurofen was less frequent during the afternoon, and this appeared to reassure her that he might be improving.”*
However, at around 3.00 am the following morning (Saturday, 3 September 2022), Child WK woke and would not settle. His mother checked his temperature, which was 38.4°C, so she gave him some more Panadol and put him back in his cot. About 15 minutes later he vomited over his face, chest and the cot. She got him cleaned up and took him into the lounge room, where she nursed him until morning. She tried to feed him during this time, but he didn’t want to feed and seemed irritable.”
During the day Child WK improved a little and his mother thought he seemed a little better, but he was still not himself. He ate three solid food meals and also drank three bottles of formula, so his appetite was reassuring. His fever also appeared to have reduced, but he was lethargic and agitated. She didn’t recall him vomiting again during the day. They visited Child WK’s maternal grandmother and she recalled he looked sick, but was smiling and generally happy, so she was not concerned.
Child WK and his mother then went home and he was put to bed without incident.”
On Sunday, 4 September 2022, Child WK woke at around 5.00 am. He wasn’t making eye contact, which his mother thought was unusual. She took him into the lounge room to give him a bottle. He only took a small amount of his bottle and he was making whimpering, moaning and groaning noises. His breathing was also short and he was not interested in food. His mother was concerned, so she decided to retum to the hospital to have him medically assessed again. She called her partner, who again came over and drove them to hospital. Child WK’s mother recalled that her baby calmed down a bit during the car trip to hospital,’
Child WK and his mother arrived at the hospital at 9.41 am and Child WK was again allocated a category 3 ai triage. It was noted in the triage history that he had been seen in the ED the other day with an ear infection and his mother indicated he was no better. He was recorded by the triage nurse as miserable and upset. He had experienced fevers overnight and had vomited after being given paracetamol. WJ reported she had last given him Nurofen at 6.00 am. Child WK’s observations were recorded shortly after, at 9.50 am. His heart rate and respiratory rate were slightly elevated, he was in mild respiratory distress and his oxygen saturations were 93% on room air. His temperature was normal.”*
Child WK’s observations were entered on a Paediatric Acute Recognition and Response Observation Tool (PARROT) Chart. This chart is a tool to assist nursing staff in identifying potential early signs of sepsis or serious deterioration in a child that may trigger escalation of care or an emergency response. Based upon
24 exhibit 1, Tab 8.
25 Exhibit 1, Tab 8, 11.
26 Exhibit 1, Tab 8, 11.
27 Yexhibit 1, Tab 8.
28 ixhibit 1, Tab 15 ~ Triage Notes AM 4.9,2022.
34,
37,
observations, the chart resulted in an Early Warning Score, which prompts various actions on the Escalation Pathway. A score of 0 is normal. A score higher than 4 triggers urgent medical review. A number of Child WK’s initial observations were abnormal, resulting in an Early Warning Score of 4. This suggested at least a review by a senior nurse was recommended and consideration should be given to medical review.
In addition, Child WK’s hydration status was considered through a series of tests, including capillary refill, skin turgor and examination of his fontanelle. The notes indicated he appeared well hydrated at that time, based on the results of all the tests.*°
Child W was given paracetamol at 10.00 am. Nursing notes from that time record that he was crying and interested in feeding but looked like he may have a sore throat. The nurse identified he was teething and topical Bonjella was applied with good effect. Child WK’s mother recalled the nurse also tried to force him to feed, but he was upset and didn’t really take it. The nurse mentioned thal he needed to keep hydrated, so she gave WJ a syringe of liquid to try to give to him?!
Consistent with the indication Child WK would benefit from early review, based upon his Early Warning Score, Child WK was seen promptly for medical review at 10.00 am, about 20 minutes after his arrival in the ED. Once again, Child WK was seen by GP Dr Dijkwel that morning.”
Dr Dijkwel was aware Child WK had an earlier presentation with a suspected inner ear infection and he had re-presented at the ED for review as he was not better.
Dr Dijkwel was aware he had told Child WK’s mother to return for follow up after two days if he was not improving, so it seems he was not surprised to see him in the ED again. The notes record that Child WK presented with his mother, WJ, who seemed well, with no signs of drug intoxication (which was relevant given her history). She advised that Child WK had been drinking and sleeping well but at 3.00 am that morning he had become unsettled again. The observations taken in the ED that morning had found no fever but he was slightly tachycardic (raised pulse rate) and tachypnoeic (raised respiratory rate).??
Dr Dijkwel was asked about Child WK’s observations of increased heart rate and respiratory rate, and what that told him. He gave evidence that it could roughly indicate two things: it can indicate a child that is sick and febrile, possibly septic, or it can indicate a child that is in pain, or both. However, the fact that he did not have a fever made it appear more likely that pain was the cause of his abnormal observations. Dr Dijkwel indicated that the reason why doctors usually ask to have children observed in the ED for some time is to allow for general observations of the
29 Exhibit 1, Tab 15 - PARROT Chart 4.9.2022.
3° Rxhibit 1, Tab 15 — Triage Notes AM 4.9.2022.
31 Exhibit 1, Tab 8.
2 Exhibit 1, Tab 15.
33 Exhibit 1, Tab 15.
39,
child and also to see how the numbers trend, in the sense of whether they get worse,
stay the same or get better over time. This t
Child WK was alert when reviewed by Dr
hen allows a clearer picture to form.**
Dijkwel. Dr Dijkwel examined Child WK
and noted that Child WK still had red eardrums. His chest was clear, he had no neck stiffness and everything else in his physical examimation was normal except for a
rash on his
back. Dr Dijkwel recalled the mild red rash covered the entire back and
was blanching and not raised. Dr Dijkwel explained the blanching (where the redness disappears when touched) was important as a non-blanching rash would have caused
him to be on alert for sepsis or more serious infec t to be consistent with a viral cause. Dr rash that was not of concern, being consistent with a
raised he fe
The doctor’s impression was that it was now day h persistent bilateral red eardrums and a relapse in symp
media), wi
ion. The fact the rash was not Dijkwel assessed it to be a heat ot of different viral infections.*®
hree of an ear infection (otitis oms, so
treatment with antibiotics for the infection was indicated. Dr Dijkwel prescribed
amoxicillin 150 mg orally and indicated that he shou.
ED before he went home. It was planned tha
following day, but his mother was also told concerned.*6
After Child Wik was seen by Dr Dijkwel, he to
had been observed to appear quite anxious.
She was given education about how to give the
cool and not overdressed. She was also giv any concerns. Child WK was given his
11.00 am and his mother was given the rest of the amoxicillin syrup to take
d also be given ibuprofen in the Child WK would be reviewed the she could return that afternoon if she was
erated a small feed. His mother, who , appeared to have relaxed a little as well.
oral antibiotics and to keep her baby en advice to return to the ED if there were first dose of the antibiotic amoxicillin at with her,
with instructions to give it him every 8 hours. Child WK’s observations were within
normal limits when taken at 11.24 am and
his Early Warning Score on the PARROT
chart was calculated to have dropped to 0, wi
h his pulse rate having reduced to a
normal range and his temperature remaining normal. In terms of the comments about ‘trending’ of vital observations, Dr Dijkwel commented that Child WK’s got better, which he found reassuring at the time. He noted that Child WK’s behaviour was also
reassuring, as he was noted to be interactive and
alert.2”
Prior to Child WK going home and after Dr Dijkwel had written his notes, he recalled he had a last conversation with WJ. He remembered that she expressed some concerns, despite having appeared reassured earlier, so he asked her to come back that afternoon again at 4.00 pm. She stated that she had something on between 4.00 pm and 5.00 pm, so Dr Dijkwel recalled they agreed that she would bring
Child WK back to the ED at 5.00 pm that mother.*8
35-7 12 13; Exhibit 1, Tab 8,Tab 15 — Triage Notes AM 4.9.2022 and Tab 20.1.
36 Exhibit 1, Tab 8 and Tab 20.1.
37 T 10; Exhibit 1, Tab 15 - PARROT Chart 4.9.2022.
38 Exhibit 1, Tab 15 - PARROT Chart 4.9.2022.
day. Child WK then went home with his
42,
43,
44,
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Dr Dijkwel observed in his evidence that WJ’s interaction with her baby and her obvious concern for his welfare, rather than causing additional concern, had actually given the hospital staff some confidence that he could be looked after safely by his mother.??
WI did not bring Child WK back to the ED at 5.00 pm as arranged. Dr Dijkwel
recalled he finished at the Carnarvon Hospilal at about 5.00 pm and he left soon
after, without having seen Child WK or his mother. He did not see Child WK + 40
again.
Dr Dijkwel stated that he had known WJ for many years through presentation in the ED, antenatal care and through observations in the community. Her struggles with polysubstance use were well known and he had scen her in various states of intoxication. However, during both presentations in September 2022 she had presented well with no signs of drug intoxication and he had formed the impression she had her drug use under control. He also believed he had a good rapport with her, so he thought she would have been comfortable to return to see him, if needed.’
Dr Dijkwel gave evidence he would have liked to have seen Child WK and his mother again before the end of his shift, for the sake of continuity, in the sense that he would be able to see any changes in the child better than a new doctor who had not seen him before. Although WJ had only indicated she could come back at 5.00 pm, when his shift was finishing, Dr Dijkwel said he had thought this would at least have allowed him an opportunity to make his own assessment and then pass on his impression to the next shift. However, WJ did not return, so he did not see Child WK again. The fact that WJ did not bring her baby back at 5.00 pm did not overly concern Dr Dijkwel at the time. He explained that while he had understood in the morning that she was concerned and didn’t seem reassured, and he feels it is important to take parental concern seriously, he had not been sure whether WJ was specifically concerned about her baby being unwell or just not confident in providing his care. Therefore, he had encouraged her to come back to help support her.”
When WJ did not bring Child WK back that afternoon, Dr Dijkwel assumed that Child WK must be doing all right and his mother had decided that she didn’t need to re-present. He felt confident from his observations of her interactions with her child aver the previous two visits that WJ was an attentive mother and that she would make the right choice and bring him back if needed.
Dr Dijkwel confirmed in his evidence that “[s]epsis is always in our mind when we see a child that’s unwell,”"* so he had been considering sepsis as a possible differential diagnosis when assessing Child WK. However, at the time he did not think that Child WK showed signs he was developing sepsis. He noted that at the hospital he had been working in a team with a few very experienced nurses, and they
40 Exhibit 1, Tub 20.1.
4 Eyhibit 1, Tab 20.1.
#7 12-14; Exhibit 1, Tab 20.1.
47 13,
had agreed with his opinion and had not raised any concerns, which he would generally expect would occur if they saw signs of concern that he had missed.*5
49, Dr Dijkwel also confirmed in his evidence that even if he had taken a different approach, and kept Child WK in for observation for a longer period, it would only have been the increased observation that would have changed as his treatment on oral antibiotics had already been commenced. Dr Dijkwel agreed that observation in hospital would have created the opportunity to identify that Child WK’s condition was deteriorating sooner, bul I note from other cases that it is not clear whether a change in his treatment by that stage would have made any difference to the outcome.*7
Child WK’s mother’s recollection was that she left the hospital at around 1.00 pm to 1.30 pm (although it was likely a couple of hours earlier based on the medical notes) and she recalled her baby deteriorated from that time. He was sweating, but his temperature still seemed normal. He started to go purple in colour and seemed cold to the touch. He was rolling over in his cot and looked very uncomfortable. Later in the afternoon, his mother noted he seemed pale and his skin was blotchy. She wasn’t sure if this was due to the antibiotics and did not recall whether the hospital staff had given any warning signs to look out for in that regard, but she was worried.”®
Child WK’s mother was still staying with friends, so she asked them to come and look at her baby, to get a second opinion. They reportedly reassured her that they thought he was looking a bit better, so WJ decided she was worrying too much, She believes she gave her son his antibiotics at around 7.00 pm and put him to bed before she went to sleep herself at 7.30 pm. At 9.15 to 9.30 pm, she woke and went to check on him.*?
When she looked into the cot, she saw Child WK was lying in his cot with vomit on his chest, chin, neck and in his eyes. She scooped him up and faced him downwards, then struck him on his back a couple of times as she was worried he may have been choking on vomit. More vomit came out of his mouth during this process, but he did not begin breathing. Someone in the house called for an ambulance to attend, but
467 15,
‘7'T 15 — 16; Exhibit 1, Tab 21.
“8 Exhibit 1, Tab 8.
“9 Exhibit 1, Tabs 8 to 10 and Tab 15.
55,
then they decided to drive him straight to hospital as it was felt this would be quicker, They raced to the Carnarvon Hospital ED, arriving at 9.48 pm.
The hospital staff had received notification from the St John Ambulance Command Centre that there was a baby being brought to hospital that was not breathing, so they were on alert. A nurse ran outside to meet them when the car arrived and immediately took Child WK inside. Child WK was quickly assessed and allocated triage category 1, the highest priority. At that time, he was not breathing, had a mottled appearance and had crusted yellow vomit around his mouth and nose. He was rushed to the resuscitation bay and chest compressions were commenced.
Telehealth Service were contacted for paediatric advice at 9.52 pm and CPR then continued under expert guidance. At 9.55 pm the anaesthetist entered the room and Child WK was quickly intubated. He was given adrenaline (four doses), fluids, broad spectrum antibiotics and dextrose and good effective CPR continued. Sadly, at 10.35 pm, after 60 minutes of CPR, Child WI. remained in asystole (no cardiac electrical activity) and no reversible causes could be identified. Following a discussion amongst the staff involved in the resuscitation efforts, it was determined he could not be revived and any further CPR was futile. All resuscitation efforts ceased and Child WK was certified life extinct at 10.36 pm.*!
Two forensic pathologists, Dr Daniel Moss and Dr Kiralee Patton, performed a post mortem examination. The examination found a well-nourished male infant with no dysmorphic features and no evidence of significant injury. The brain was examined and showed no significant abnormalities.**
There were signs of a possible infection in the lungs, which upon microscopic examination showed patchy inflammatory changes on the surface and bacteria in the form of gram-positive cocci on the pleural surface of the left lung. Further, the portal tracts within the liver were markedly expanded by a mixed inflammatory cell infiltrate; occasional inflammatory cells were seen engulfing red blood cells (haemophagocytosis). There was no evidence of inflammation or infection in the other body tissues.
Microbiology analysis showed abundant growth of Streptococcus pyogenes from the left pleural fluid (from the left lung) and also some growth from the left and right lungs, trachea, spleen, nose swab, throat swab and epiglottis.™
Parechovirus RNA was also detected in the epiglottis, pleural fluid and small and large bowel. In addition, Rotavirus RNA was detected in the small and large bowel, but was likely associated with recent rotavirus immunisation. Virology testing was otherwise negative,
5° Exhibit 1, Tabs 8 to 10.
5} Exhibit 1, Tab 15.
2 Exhibit 1, Tab § and Tab 7.
33 Exhibit 1, Tab 5.
55 Exhibit 1, Tab 5 and Tab 6.
Toxicology analysis showed medications consistent with the known medical treatment and a low level of alcohol that was interpreted with caution as it was likely related to decompositional changes.
At the conclusion of all investigations, the forensic pathologists formed the opinion the cause of death was Strepfococcus pyogenes (Group A Strep) and parechovirus infection. In their opinion, the death was due to natural causes. | accept and adopt the forensic pathologists’ opinion as to the cause and manner of death.*”
Streptococcus pyogenes is commonly known as Group A Strep. It can be spread by respiratory droplets or less commonly through physical contact with skin lesions.
Group A Strep can be carried by people in their throat or skin without any symptoms of illness, so it is common for it to be transmitted and passed around the population without any realisation that people have come into contact with the infection. If illness does occur, it is usually mild, such as a sore throat (often called ‘strep throat’).
However, sometimes Group A Strep can cause life-threatening disease. This is known as invasive Group A Strep, and is when it gets into parts of the body where it is not usually found, such as the lungs or blood. Sadly, it seems this is what happened in Child WK’s case. There was evidence of inflammation in his lungs, particularly the left lung, and some bacteria were seen in keeping with the presence of Group A Strep. The presence of Group A Strep in the spleen was also possible further evidence of invasive Group A Strep. ‘The microscopic appearance in the liver was in keeping with sepsis.**
In the post mortem findings, parechovirus infection was also noted. Human parechovirus infections are very common in children and typically cause no symptoms, or clse mild symptoms such as gastroenteritis or influenza-type illness.
Parechovirus can also cause, or be associated with, red cardrums/otitis media in children. However, it is known that in rare cases it can cause serious illness in babies and young children. Characteristically, young infants present with fever, irritability and occasionally a diffuse rash. Severe disease can manifest as sepsis-like and unusual manifestations include hemophagocytic lymphohistiocytosis, which is in keeping with the microscopic findings in Child WK’s liver.’ There is no treatment for parechovirus, but when a baby or young child suffers a severe infection, they may require supportive treatment in hospital, and if it develops into sepsis, then the baby or child will require antibiotics.
As noted above, the forensic pathologists who conducted the post mortem examination of Child WK concluded it was a combination of these two infections hat together caused Child WK’s death.© Dr David Speers, a highly experienced infectious diseases physician and clinical microbiologist, explained in a previous coronial inquest matter that one of the mechanisms of Group Strep A to get through he skin barrier or the mucosal barrier of the throat is from a preceding viral
7 Exhil 38 Exhil Exhil © Exhil
bit 1, Tab 5, bit |, Tab 5 and Tab 21.
bit 1, Tab 5.
it 1, Tab 5.
65,
infection, which can disrupt the normal protective mechanisms that keep the bacteria away from entering the body."' It seems that is likely what occurred in this case. In short, it seems Child WK got a parechovirus infection, which then allowed the Group Strep A infection to invade his little body.
Child WK’s death was investigated internally by the WA Country Health Service as part of a Serious Clinical Incident Investigation. Whilst not required to do so, the WA Country Health Service voluntarily provided the outcome of that investigation to the Court. °
The Investigation ‘eam included a Perth Children’s Hospital (PCH) Paediatrician, who is external to WACHS, as well as senior staff members from WACHS, including the Clinical Director of Emergency Medicine, a Paediatrician and a Paediatric Nurse Practitioner. The investigation team met on three occasions, with further consultation by email and a visit by the Team Facilitator to the Carnarvon Hospital ED. 1 am informed open disclosure was also offered to Child WK’s mother as part of the process.
At the conclusion of the investigation, the panel did not identify any omissions in care delivery. They concluded all nursing and medical care provided was appropriate for the management of a child presenting with likely infectious syndrome on both presentations. As part of its consideration, the panel had considered other sepsis pathways, separate to the WACHS PARROT chart, to sce if use of a different pathway might have prompted consideration of sepsis. Only the PCH Sepsis Guideline would have raised a Sepsis Escalation Prompt, on the basis that Child WK fell within a ‘High Risk Group’ for increased prevalence of sepsis due to ‘rural, remote or socioeconomic deprivation’ but otherwise his physiological observations and clinical picture would not have triggered activation of the guideline. ‘The panel noted it was evident Dr Dijkwel had some knowledge of WJ and her general background, as well as an inherent knowledge of the town and the town resources, and he had properly put in place “significant ‘safety nets’” in the discharge planning for that reason.
Later information that the sepsis was connected to Streptococcus pyogenes, a pathogen that while generally causing mild disease can also cause severe invasive infection and sepsis, led WACHS Safety and Quality to convene a meeting to consider if this required any change to the initial clinical incident analysis. It was noted that a recent Australian paper had described the increasing incidence of this infection in Australia, peaking in children under one year of age, as was the deceased. Risk factors for severe disease include viral coinfection, which was also present in this case. However, it was also noted that there was a high incidence of children with this disease seeing a doctor and being sent home before being admitted
61 Rxhibit 1, Tab 21.
& Byhibit 1, Tab 14.
6 Bxhibit 1, Tab 14.
© Bxhibit 1, Tab [4.
71,
to hospital for treatment. Given the safely netting put in place in this case, and that the management provided was consistent with guidelines, and further noting that the antibiotic prescribed did have activity against the identified pathogen, it was concluded the initial investigation and outcomes remained an accurate reflection of the event.®
The only identified opportunity for improvement, which was not considered to be a contributing factor, was for better recording of the information that Child WK was a child in care.
Dr Andrew Savery is the Clinical Director Paediatrics at WACHS and works as a consultant paediatrician in the Kimberley. Dr Savery was a panel member involved in the Clinical Incident Investigation (SAC 1) into Child WK’s death. Dr Savery provided a report addressing the quality of Child WK’s treatment and medical care to the Court and also gave evidence at the inquest to speak to his report and the SAC 1 investigation. Dr Savery never met Child WK or his mother, so his opinions were based solely on his reading of the relevant documents and his involvement on the panel in the SAC 1 investigation.*”
After reviewing the notes of the first presentation, Dr Savery expressed the opinion that given the clinical picturc, in his view the treatment plan for symptomatic treatment and review in the next day or two if he did not improve, was “a reasonable safety net plan given that there is little evidence that antibiotics have utility in the reatment of otitis media and that the most likely cause of bilateral tympanic membrane redness, is viral.”** Dr Savery agreed that at that time Child WK was probably expericncing a viral illness and not a bacterial one, noting that this sort of presentation with a viral illness is incredibly common. In that context, Dr Savery indicated he held no concerns for the care provided to Child WK on this day.
n relation to the second presentation, on the morning of 4 September 2022, Dr Savery noted Child WK’s set of observations taken on arrival showed mild respiratory distress, reduced oxygen saturations and a fast heart rate, but his temperature was normal at 36°C. This was despite Child WK’s mother indicating in her statement he had experienced higher temperatures at home. Dr Savery observed hat this could have indicated that Child WK’s temperature was “spiking,””” but this ind of fever that then comes down is a fairly non-specific finding in children, with both bacterial and viral illnesses, so it did not indicate anything significant on its own.
Dr Savery noted that the capillary refill time was slightly longer than normal, which can be a marker that the circulation isn’t as good as it should be, but this can often be seen in children with viral illnesses, particularly if they have recently been febrile, so it was not overly concerning and was explicable in the context of the other
6 Exhibit 1, Tab 14.
66 Exhibit 1, Tab 14,
57 Exhibit 1, Tab 22.
8 7 21; Exhibit 1, Tab 22, p. 2.
69 T 20 — 21, 32; Exhibit 1, Tab 22.
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information. Dr Savery explained that if the capillary refill time had been more prolonged and abnormal, it would have been a marker that perhaps there was a more significant deep-seated and worrying infection brewing in Child WI. However, that was not the case at this time.’! Neck stiffness, which may be a sign of meningitis when combined with a rash, was also specifically excluded.
In relation to the rash on Child WK’s back, Dr Savery agreed with Dr Dijkwel’s explanations that blanching rashes, like the one present in this case, are often associated with a virus in children and are classically reassuring that it is probably not a serious infection. A non-blanching rash on the other hand, is more classically associated with sepsis and is therefore a significant finding of concern. Dr Savery observed that in hindsight, the blanching rash that was seen on Child WK’s back may well have fitted with the parechovirus infection that was later identified at post-mortem.”
Dr Savery expressed the opinion that Dr Dijkwel’s decision to commence Child WK on oral antibiotics at that time was appropriate, given the child was not better and there was persisting parental concern. He also commented that in the context of the treatment occurring in a more remote and regional area, it was also “a very, very safe option.” Dr Savery observed it may still have fitted the picture of a viral illness, but given the child was not getting better, increasing the intensity of the treatment was appropriate.”
Once again, Dr Savery considered the plan to review the next day or even that afternoon, if his mother was concerned, was appropriate management on the evidence available at the time. This included the fact Child WK’s respiratory rate and heart rate had returned to the normal ranges and his oxygen rate had improved from 93% to 98% on room air, but he was still afebrile (no fever) and that there was an appropriate safety net plan for deterioration.”°
Dr Savery commented that if the respiratory rate and heart rate had not come down and had remained elevated in the absence of a fever, he would have considered that “very worrying for a deep-seated sepsis.””° However, the fact that the observations responded to simple treatment and Child WK looked well made it more reassuring that he did not have a bacterial mfection. However, Dr Savery gave evidence “you can never be 100 per cent about these things,””’ and in this case it seems to have been the case in hindsight that Child WK did have a bacterial infection at that time.
Dr Savery was asked in evidence whether he had identified any red flags or missed signs that care should have escalated, and he answered that he had not. Dr Savery agreed with Dr Dijkwel that even if he had taken a more cautious approach and kept Child WK in hospital for a longer period of observation on 4 September 2022, it is
BT 35, ™T 35, ® Exhibit |, Tab 22.
unlikely the treatment would have changed, and it would have been simply an opportunity to conduct more regular observations and watch the evolution of his illness, looking for any signs of deterioration before the treatment changed.”
Dr Savery observed that by the final presentation, Child WE was not breathing and had no cardiac activity, so CPR was commenced immediately. The CPR continued for a lengthy period, with input from appropriate specialists. In Dr Savery’s assessment, the resuscitation efforts aligned to the Paediatric Life Support Algorithm (non-shockable pathway) and appropriate attempts were made to correct any reversible causes of cardiac arrest before the difficult decision was made to cease all resuscitation efforts. In Dr Savery’s opinion, the resuscitation attempts were thorough and aligned with the algorithm very well.”
Dr Savery had been an active panel member in the SAC 1 investigation and he concurred with the findings of the investigation, which are consistent with his opinions expressed in his report and orally at the inquest. Dr Savery noted that the panel had considered several different sepsis recognition and response tools from other health services as part of the investigation, to see if another tool would have guided the treating team who saw Child WK to take a different management plan.
However, all of the pathways consistently reflected that based on the information at the time, the decision to discharge Child WK home on oral antibiotics on the morning of 4 September 2022 was a reasonable decision. Dr Savery also advised that WACHS was in the process of implementing the Department of Health’s Statewide Paediatric Sepsis Pathway (PSP) in April 2025, which would allow for a standardised approach to the management of Paediatric Sepsis at all sites across the state, which will ensure consistency of approach for all health staff and may improve the response o a deteriorating child. Along with this implementation, WACHS will be implementing a tool to aid recognition of sepsis in children, based on the National Institute for Health and Care Excellence Guidelines from the UK and is designed to give staff who may have less experience with paediatric patients, an early flag that a child is critically unwell. The PARROT observation chart will also be updated to link o the new PSP and there will be an education package to accompany it.*
Dr Savery works in the Kimberley, where the PSP has been trialled, and he considers he new PSP has made the pathway a little clearer. The new chart has added a scoreable item related to the child’s behaviour, but he did not suggest any of these improvements would have changed the outcome in this case.*!
Based upon his own knowledge and expertise, Dr Savery indicated that he did not think further tests, investigation or treatments were necessary or warranted on 2 and 4 September 2022. He noted the “symptoms were non-specific and on second presentation, oral antibiotics were prescribed,”*? which seemed reasonable and appropriate treatment at that time. Whilst the outcome in this case was tragic,
T 36; Exhibit {, Tab 22.
8 Exhibit 1, Tab 22.
517 38 - 39,
2 Exhibit 1, Tab 22, [36].
Dr Savery did not consider there had been any red flags missed or oversights in the medical care provided.
Dr Savery agreed with the general proposition that it appeared Child WK had first contracted the viral infection, parechovirus, which caused him to become unwell and led to the first presentation to Carnarvon Hospital. Over the following days, the viral infection has created a window for the Group A Strep bacteria to enter Child WK’s body and the bacterial infection has then spread. The combination of the two infections, and particularly the invasive bacterial infection, has eventually overwhelmed Child WK, causing his death.
Whilst Child WK was commenced on oral antibiotics, which could have had some effect on the brewing bacterial infection, Dr Savery noted that the oral antibiotics prescribed to Child WK would not have been as effective as intravenous antibiotics in treating the infection. However, he gave evidence that even with retrospect, he did not think there was any indication on the morning of 4 September 2022 that intravenous antibiotics were appropriate at that time. In terms of the type of antibiotic prescribed, Dr Savery indicated it was an effective antibiotic against Sireplococcus pyogenes and he thought it was a very appropriate antibiotic to be given to Child WK that day.
Dr Savery observed that this kind of infection “can be very overwhelming and very quick,”** so it is unclear whether it would have made any difference to this case if Child WE had been seen again at the hospital on the aflernoon of 4 September 2022.
Dr Savery gave evidence this is particularly the case in young infants, as the speed at which it can overwhelm a child increases in a younger paediatric patient, so the fact hat Child WK was a young infant of only seven months old may have been a significant factor in this case.
Dr Savery gave evidence that sepsis “is an exceedingly hard diagnosis to make in children, and it’s an exceedingly rare diagnosis.”** Tt is for this reason that the identifying tools, such as the PARROT chart, are in place to guide nurses and doctors and hopefully be able to protect children, but Dr Savery commented that these tools are nol foolproof and they are not diagnostic tests, so there will sadly still be cases where the diagnosis is not made until it is too late.*”
The PARROT chart is a type of sepsis recognition tool, designed specifically for children. It assists with triaging unwell paediatric patients where infection may be responsible to help recognise cases of critical illness. This is necessary because classic signs of septic shock, like low blood pressure, occur later in children compared to adults due to their capacity to compensate, so recognising sepsis cases
in children can be challenging. However, it is also important to note that many children presenting to the ED with common childhood infections meet these sepsis recognition criteria, but only a small fraction subsequently require critical care.®®
The two key lines of treatment for sepsis are antibiotic therapy and fluid support, with the early administration of antibiotics important for good outcomes. However, antibiotics are not effective for viral infections, and I am informed that it is generally suggested that the small benefits of antibiotic treatment for otitis media are considered not worth the risks to a child of having antibiotics, such as risk of allergic reaction, as well as the risks to the community of excessive antibiotic use.®?
I understand that the incidence of invasive Streptococcus pyogenes disease has been reported to be increasing in a number of countries, including Australia, over the last two decades, although the reasons why are not entirely clear. There is a general understanding that sepsis, while rare, needs to be considered when a child presents to the ED with viral-type symptoms, and Dr Dijkwel gave evidence he had sepsis in the back of his mind each time he reviewed Child WK. However, it is generally accepted that recognising a patient with sepsis can be challenging as the classical clinical features may be absent, and it is notably more difficult in children, who can appear well and then very rapidly deteriorate.”
Child WK had both a Streptococcus pyogenes or Group A Strep infection and a parechovirus mfection on the morning of 4 September 2022, and these eventually developed into sepsis sometime on 4 September 2022. However, he did not show the classic clinical signs of sepsis, such as fever, when he was seen by a doctor on the morning of his death, which suggests his compensatory mechanisms were working to mask his condition until he was overwhelmed and his system collapsed.
In the circumstances, and noting the expert evidence before me, I am satisfied that in these circumstances, there was no failings on the part of the doctors and other health staff who treated Child WK on 2 and 4 September 2022 at Carnarvon Hospital.
The Department of Communities was notified of Child WK’s unexpected death and conducted its own internal review into the records of Communities’ involvement with the family. The Response to Death Notification that was then prepared, which reflects that there was extensive and very complex interaction between Communities and Child WK, his mother, siblings and grandparents.
Although Communities identified a number of opportunities where different decisions and actions may have been taken with Child WK and his family, it was noted that none of them (either individually or collectively) would have altered the sad outcome in this case.?!
88 Uxhibit 1, Tab 21.2.
87 32.
% Exhibit 1, Tab 21.
} Exhibit 1, Tab 13.1 —- Supplementary Report.
92,
NO we
94,
WJ’s mother (Child WK’s maternal grandmother) provided a statement after her grandson’s death and indicated she had initially been angry with Communities’ staff for taking Child WK into care immediately after his birth as she thought her daughter was in a good place and would have been able to care for him. However, given he was placed with her and she was able to ensure that Child WK and his mother spent time together, she had become more accepting. During those initial weeks, Child WK’s grandmother observed that her daughter was bonding well with Child WK before they both left to go to rehabilitation together. While they were at the rehabilitation facility, she spoke regularly with Child WK’s mother and they also exchanged some letters. It was clear mother and baby were doing well and Child WK’s grandmother did not have any concerns when her daughter chose to leave rehabilitation early to return to Carnarvon.”
Once they were back in Carnarvon, Child WK’s grandmother saw that WJ was very protective of her son and she saw no reason to suspect WJ was using drugs again.
Child WK’s grandmother believes her daughter was doing a good job caring for Child WK and she held no concerns for him in the lead up to him becoming wowell.%
Communities also acknowledged that WJ had shown resilience and capacity for change and she had worked positively with Communities’ staff to create safety for Child WK. It was accepted in hindsight that the support provided to WJ to leave Cyrenian House early may have been inadvertently inconsistent with a Court outcome, but I note that WJ’s decision was very sudden and Communities staff were focussed on safety planning around this decision, Obviously in future cases it is important for Communities staff to understand, and adhere to, any Court outcomes, which has been acknowledged by the Executive Director of Child Protection and Family Support in her review of this case.”
The Communities’ review of this case also noted that Child WK fell within the description of a ‘High Risk Infant’ given his young age, and Communities has adopted a new approach to working with High Risk Infants as they are acknowledged o be particularly vulnerable. Further steps have been taken to improve safety for High Risk Infants within Communities’ care since Child WK’s death, but it does not appear to me that any of the changes would have impacted on his death if they had been in place earlier.”
The circumstances of Child WK’s death reveal his mother sought appropriate medical attention for him on more than one occasion and there is no indication in the hospital records or witness statements that WJ’s known longstanding drug and mental health issues were a concern in the lead up to his death. Her actions were hose of a caring and attentive mother in following the medical advice and repeatedly secking help when she was concerned. ‘The Department was notified by hospital staff after his sudden death and conducted their own inquiry, with a focus on the safety of Child WK’s sibling, Child MWA. The Department’s review found no information to
” Exhibit 1, Tab 11.
° Exhibit 1, Tab 11.
°5 Exhibit 1, Tab 13.1 — Supplementary Report.
suggest Child WK’s mother’s actions or inactions played any part in his death, or to raise any concern about her care of her son prior to his death.”
Police were also notified, given he was a child in care, so his death was a reportable death. Police officers attended the hospital and examined Child WK but did not speak with his mother. They examined the home address as well and spoke to witnesses and were satisfied there was no suspicion of criminality or involvement of another person in his death.”
Child WK was a very loved baby boy. All the evidence before me indicates that his mother was a loving and conscientious caregiver for her baby son during the last few weeks of his life. After finding out unexpectedly that she was pregnant with him, she had worked hard to cease her drug and alcohol use so that she could be a good mother to him, as well as her other children. All the evidence suggests she had succeeded thus far, which was why Communities staff had been content to allow her baby to leave Cyrenian House with her and remain in her care when she returned to Carnarvon. The loss of any child in such circumstances is tragic, but it is particularly sad to see all of the hard work WJ had taken to be a good mother undone by a natural event that she could do nothing to avoid.
Unfortunately, invasive Group A Streptococcal infection is a rare, but known, cause of death in young children like Child WK and parechovirus infection can also lead to fatal complications in rare cases in young infants. These infections can change rapidly from a normal childhood illness to a life-threatening event with little warning. Tools such as the PARROT chart have been implemented in hospitals for this very reason, but sadly it is still the case that sometimes the child will compensate for a significant period and the signs of developing sepsis will be subtle, so when the deterioration in clinical state occurs it will be too late to save them.
That is what occurred in Child WK’s case. His mother could see he was unwell and had appropriately sought medical treatment for him on two occasions, but at that ime his symptoms were non-specific and had all the hallmarks of a common childhood ear infection, which will often resolve on its own. He was commenced on antibiotics after the second presentation, as it was apparent the infection was not resolving on its own. I note the doctor could also see Child WK’s mother wasn’t entirely comfortable leaving the hospital, which is often a warning sign, and in hindsight her mother’s instinct was right. However, at the time she was sufficiently reassured and she agreed to take her baby home, on the understanding she could bring him back if he got worse or she remained worried. She did not go back to the hospital that afternoon, trusting that the antibiotics would make her son better. I understand the antibiotics would have had some effect, but Child WK had only received two doses orally by the time he rapidly deteriorated that night, and in the meantime the infection had become overwhelming.
% Exhibit 1, Tab 13.1 — Supplementary Report.
7 Exhibit 1, Tab 2.
This is a very sad case, and it was obvious at the inquest what an enormous personal toll her son’s death has taken on WJ. She cannot understand how, after seeking medical help, she could be sent home with her vulnerable, ‘precious and fragile baby”®* with the reassurance that he should be fine, only for him to then die in a matter of hours. J acknowledge her understandable distress and confusion but I must be guided by the expert medical advice, which tells me that these kinds of deaths while rare, do still occur without any identifiable fault or omission on the part of the nurses and doctors involved.
I note that this inquest was mandatory as Child WK was a child in care at the time of his death, but all of the evidence indicates that his death was unconnected to his social situation and was simply a tragic natural cause event.
I extend my sincere condolences to WJ for the loss of her youngest son, and to Child WK’s siblings for the loss of their baby brother.
S H Linton Deputy State Coroner 5 November 2025
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