Coronial Findings

Record of Investigation into Death

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Peter Henric Wilson, Coroner, having investigated a death of a child



“the deceased” was a Student.

I find that the deceased died as a result of Hypoxic Brain Damage.

At the time of the deceased person’s death he was being treated by a medical practitioner.


The deceased was taken to his grand mother’s house at by his father. The deceased would regularly visit his grand mother, staying most weekends.

The deceased had a medical condition which was type 1 diabetes, which meant that he was insulin dependant and required an injection of insulin before breakfast in the morning and before tea of a night. The deceased’s father was the one who normally administered the injections, however his grand mother would administer them when the deceased stayed with her.

His grand mother was educated at the Steele Street Diabetic Centre some seven years ago and was informed on how to administer insulin, what to do when/if the deceased’s sugar levels were low, what to do if the deceased had a hypo and received general information about diabetes and what sort of food was required.

The deceased required two types of insulin which had to be mixed together to produce the required dose. The insulins were Act Rapid and Protophane and the amounts would change daily depending on his sugar levels.

On arriving at his grand mother’s home, the deceased had already been given his injection by his father at around 6p.m. The deceased and his grand mother sat down to tea as the deceased is required to have food half an hour after his injections. After tea the deceased played his game boy, watched television, played with the pet dog and read which was normal during his stay and normally retired to bed around 9.30p.m.

The next morning, the deceased got up as usual around 8a.m and as his normal practice, he checked his blood/sugar levels prior to his grand mother giving him his injection, then sitting down to breakfast. Throughout the day the deceased was fine and everything was normal. That evening he had his injection around 6p.m. and then tea half an hour later before sitting down to watch a movie on the television. The movie ran till about 11p.m. with the deceased having some supper around 9p.m. which was usual for him before going to bed for the night.

On Sunday the deceased slept late and it was closer to 9a.m. before his grand mother went to wake him. The deceased checked his blood/sugar levels which were 3.6 which were alright and after his injection he had his breakfast, however he had it in bed as he told his grand mother that he was feeling tired and just wanted to watch television in bed.

His grand mother left him in his room and began to do her normal chores such as housework before checking on the deceased around 10.15a.m. At this time the deceased was sat up in bed watching television so his grand mother went back to the housework until 11.15a.m. when she decided it was time for the deceased to have his morning tea. On entering the room she saw the deceased was unconscious so she got some honey and rubbed it on his gums as she thought he was having a hypo (low blood/sugar level), however she noticed that he wasn’t breathing and there was no pulse. She immediately rang for an ambulance and commenced CPR. She continued CPR until the ambulance arrived.

A check of the deceased’s blood/sugar levels by ambulance officers revealed a level of 8.3 which is inconsistent with the deceased having a hypo. The deceased was conveyed to the Mersey Community Hospital at Latrobe where despite the best attempts of hospital staff, he passed away.


Whilst the primary cause of death is Hypoxic Brain Damage, there is a lack of information to fully explain the antecedent cause as a number of the deceased’s organs were harvested for donation and were therefore unable to be examined.

This death has been the subject of careful consideration by the Paediatric Mortality and Morbidity Sub-Committee and has also been referred to Doctor Fergus Cameron, Paediatric Endocrinologist at the Royal Hospital Melbourne and Doctor Simon Parsons, Staff Specialist, Paediatrics at the Royal Hobart Hospital.

Some hypotheses which may explain this death are, a level of nutritional deficiency may have predisposed the deceased to the event that caused his death (eg: thiamine deficiency), hypoglycameia unawareness (no perceived symptons) or the more recently described as the ‘dead in bed sydrome’ which has been associated with nocturnal hypoglycaemia or an underlaying prolonged QT sydrome, short QT sydrome, WPT syndrome, Bruguda syndrome or some other cardiomyopathy/myocarditis condtion that predisposed him to a sudden death.

Having regard to information available to me, it is obvious that there is an inadequate management of diabetes type 1 on the North West Coast during childhood and adolescence and literature and international acceptance shows that the care of such children should be managed by specialised diabetes teams. There are many children with type 1 diabetes in North West Tasmania who receive little or no specialised care. Another issue relates to Paediatric ICU services in Tasmania where the management of brain dead children is complex and should be undertaken in a paediatric centre.

Taking into account all the evidence before me, I am of the opinion that the cause of death is Hypoxic Brain Damage attributed to a complication of diabetes where the contributing factors/possibilities can not be clearly ascertained.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

DATED : Thursday, 14 April 2005 at Launceston in the state of Tasmania

Peter Henric Wilson