Record of Investigation into Death (With Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

These findings have been de-identified by direction of the Coroner pursuant to S.57(c) of  Coroners Act 1995

I, Olivia McTaggart, Coroner, having investigated the death of

Baby R

BY AN INQUEST HELD in Hobart in Tasmania on 31 May 2011, find as follows.


Baby R was born approximately 15 weeks premature on 7 January 2010. This assessment of prematurity is based on her level of development and a recorded birth weight of 1880 grams as her mother’’s antenatal visits were inconsistent. She is the second child for her 17 year old mother, and the first for father. Her brother J was 19 months older than baby R.

When born, baby R was noted to be pale and made no respiratory effort, causing her to require immediate resuscitation and ventilation support. She was diagnosed with oesophageal atresia and tracheoesophageal fistula. These conditions, which severely impacted upon her ability to breathe and orally ingest nourishment naturally, necessitated her evacuation to the Royal Children’s Hospital in Melbourne for specialist anaesthetics, surgery and intensive care follow-up support. She remained in the Children’s Hospital until 7 March primarily for the care of this condition.

During Baby R’s early weeks of life she was noted to have several other congenital abnormalities, including:-

  • tracheomalacia - this is where the wall of the trachea is soft and this flexibility increases breathing difficulty;

  • her left nostril was permanently blocked and she constantly wheezed when breathing;

  • three ventricular septal defects - these were small holes between the chambers of her heart which initially reduced the effectiveness of the heart to pump blood, however these self-repaired as she progressed;

  • low thyroid hormone levels;

  • larger-than-usual ventricles within her brain - this allowed for an increase in fluid and therefore resulted in pressure on the soft brain tissue within this area; and

  • metopic craniosynostisis - a condition where there is a premature fusing of the bones in the skull which, in baby R’s case, resulted in an abnormally shaped pointy forehead.

Baby R also had poorly developed muscle tone which impacted upon her ability to successfully develop feeding habits.

Baby R returned to Tasmania and the Royal Hobart Hospital on 7 April, aged 3 months, where she remained as an inpatient until 28 June. During this period she continued to have difficulty feeding and initially was nasogastrically tube-fed while she developed bottle-feeding habits. She also suffered recurrent bouts of viral bronchiolitis, the second of which necessitated nine days in the intensive care unit where, at times, she required ventilation.

Also during this period ultra-sound examination noted an increase in the size of the ventricles within her head but identified a loss in brain matter, rather than an increase in fluid in the area. The connecting tissue between the right and left sides of the brain was also noted to be poorly formed. Genetic investigations discovered a duplication of chromosome 16, which can be associated with developmental delay and autism, and was suggestive of a unifying cause of baby R’s abnormalities. It was further noted that her motor, language and social skills, though progressing, were markedly behind the level of her peers. Baby R was feeding by bottle when discharged on 28 June 2010.

Child Protection Issues:-

While in the Royal Children’s Hospital in Melbourne, Child Protection Services (Victoria) were notified of baby R’s circumstances due to the infrequency of visits to her by her parents, even though they were located in hospital-specific accommodation nearby. Hospital staff also expressed concerns on the ability of her parents to be able to adequately care for her, given their lack of daily engagement with her and perceived non-appreciation of the complexity of issues she presented for ongoing care.

While baby R was an inpatient at the Royal Hobart Hospital on her return to Tasmania her parents continued to have perceived social difficulties and on 18 May 2010 an Assessment Order, pursuant to s.22 of the Children, Young Persons and their Families Act 1997, was issued in the Magistrates Court (Children’s Division) at Hobart, effective for a period of 4 weeks. The primary concerns were with the parent’s ability to adequately respond to the specific and high care requirements of baby R while still maintaining the needs for her 2 year old brother.

The order placed baby R in the custody of the Secretary of the Department of Health and Human Services; authorised her examination and assessment; authorised the Secretary to question and/or require written reports form any person, other than a child, to assist in the examination and assessment of baby R; and authorised both of baby R’s parents to each be assessed in terms of their parenting capacity and ability to act protectively of baby R.

On 11 June 2010 the period of assessment was extended by eight weeks in an Assessment Order sought, and granted, under s.22(5) of the Act.

On completion of the examination and assessments an Interim Care and Protection Order was sought and granted on 2 August, pursuant to s.42 of the Act, for baby R’s immediate future. The order granted custody and guardianship of baby R to the Secretary of the Department of Health and Human Services, and allowed access to baby R for each parent, by agreement or under the reasonable directions of the relevant Child Protection Officer.

On 9 August the conditions of the order were continued and the matter adjourned until 27 September 2010 to facilitate an s.52 conference between all parties. However, baby R passed away three days later at the Royal Hobart Hospital on 12 August 2010.


On 16 July 2010, while in care, baby R was taken to a General Practitioner due to 2 days of nasal discharge and noisy breathing where she was diagnosed with a respiratory tract infection. She was prescribed amoxicillin and baby R’s appointed carer, was advised to return or seek assistance at a hospital if baby R deteriorated further.

On 2 August 2010 CPS were advised that baby R was unwell and she was taken to DEM at the RHH, pale and struggling with breathing. She was diagnosed with bronchiolitis but was not admitted due to the current health experience of the carer in treating children with special needs.

Three days later, on 5 August, baby R again attended DEM at the RHH. She was reviewed by a paediatrician who noted that while she was coughing and wheezing she was feeding well, was gaining weight and was well hydrated. She was discharged with further intervention considered unnecessary.

On 11 August 2010 CPS were advised that baby R’s cough had improved but there were concerns on her inconsistent feeding and constant pale colour. She fed well, but slowly later that evening, and went to bed about 10pm.

She slept well and awoke the following morning around 6.30am before being fed and dressed in preparation for a home visit with her parents. When Ms M, baby R’s appointed Family Support Officer, arrived to collect her for the visit it was noted that she was pale with a blue tinge to her skin. Baby R slept in the car on route to her parent’s home but awoke on being removed from the vehicle on arrival.

She slept for the next hour and a half in the arms of both parents with it noted that she wasn’t coughing as much as usual. Baby R was woken around 11.40am to be fed but appeared very lethargic and fed poorly. The formula bottle was reheated with little positive effect. She was changed but remained lethargic and unresponsive to prompts from her mother. Her lips were noted to be blue in colour and there was little movement in her legs.

Baby R was carried to the car by her father and when being placed in the seat it was noted she was not breathing. The ambulance was called and CPR immediately commenced pending its arrival. Ambulance staff noted that baby R was not breathing and not showing any cardiac output. Advanced airway procedures were unsuccessful due to baby R’s malformed airway structure and while vascular access was achieved through intraosseus needle she remained unresponsive to CPR and adrenalin shots.

Upon her arrival that DEM it was noted that he pupils were fixed and dilated and she was cooling. After she remained unresponsive to CPR and continued to display no cardiac output an informed decision was made to cease resuscitation efforts. Baby R was declared deceased at 1.15pm.

A post-mortem examination of Baby R, by the Director of Statewide Forensic Medical Services, Dr Christopher Lawrence, determined the cause of her death to be aspiration pneumonia due to a combination of treated congenital oesophageal stricture/fistula and peri-ventricular white matter loss in the brain due to prematurity. He also noted that one heart valve had not formed.

Dr Williams a paediatrician with the Royal Hobart Hospital, who most consistently treated baby R, prepared a report for the Coroner in which she indicated that there was no single medical term for the constellation of abnormalities and difficulties suffered by baby R. She indicates that she believes baby R’s issues to be initiated by a genetic syndrome, and due to her progressive neurological deterioration she could not be expected to enjoy a long life.

Findings & Comments:

A comprehensive investigation into the circumstances of baby R’s short life and issues that led to her death was conducted by police.

I accept the determination of Dr Lawrence in relation to the cause of baby R’s death being aspirational pneumonia due to a combination of treated congenital oesophageal stricture/fistula and peri-ventricular white matter loss in the brain due to prematurity.

I also accept the opinion of Dr Williams that the constellation of abnormalities and difficulties with which she was afflicted was a genetically based syndrome which, due to her progressive neurological deterioration, left her little prospect of surviving her toddler years.

I find that the care arrangements put in place by Child Protection Services gave baby R the best chance of physical care while allowing for her parents to have regular and quality contact with her. Baby R’s parents were devastated by the loss of their baby, and they had become increasingly committed to her care and wellbeing.

All other persons engaged in baby R’s care and support, particularly those engaged for Child Protection Services, have been impacted by her passing. Their efforts towards her health and welfare can only be commended.

It is unnecessary for me to make any formal recommendations.

I conclude this matter by conveying my sincere condolences to baby R’s parents.

DATED: 31 May 2011 at Hobart in the State of Tasmania.


Olivia McTaggart