5 days ago
Coroner finds 'lost opportunities' prior to death of eight-month old infant
Queensland's deputy coroner has found a series of "lost opportunities" surrounding the death of an eight-month-old boy at his north Queensland home.
Daniel Thomas Wright was born in the Townsville University Hospital at 24 weeks' gestation in July 2018 and remained there until he was discharged to the Mackay Base Hospital (MBH) on February 6, 2019.
The following two months included some time at home along with multiple presentations to the Mackay and Bowen hospitals.
He died on March 30, 2019 — 11 days after being discharged from MBH for a second time.
Deputy Coroner Stephanie Gallagher has this week handed down her findings after hearings in 2024 examined whether it was appropriate to send Daniel home into the care of his parents, who were reported in the findings as having intellectual impairments.
The inquest also examined the sharing of information between the Townsville and Mackay hospitals, health services and the Department of Child Safety.
The inquest heard that an autopsy found the baby died due to prematurity-associated lung and bowel disease and had a series of hospital admissions for weight loss.
Hospital workers in Townsville and Mackay gave evidence about the difficulties Daniel's parents, Zara Williams and Benjamin Wright, had in understanding his needs and their ability to comply with his feeding.
A social worker at the Townsville University Hospital, where the baby stayed for his first seven months, told the inquest she had concerns about Daniel's parents' capacity to care for themselves and raise him.
She said she did not contact the Department of Child Safety because the baby was not ready for discharge at that time.
Daniel was first brought to the department's attention in February 2019, after he was moved from Townsville to MBH.
Two days after he was discharged in Mackay, Daniel was taken to Bowen Hospital and transferred the following day back to MBH.
His case was then referred to the Suspected Child Abuse and Neglect (SCAN) team, but Daniel's recovery saw him discharged from MBH for a second time on March 19, the inquest heard.
He died on March 30.
In her findings, Ms Gallagher described the decision to discharge Daniel from Townsville to Mackay on February 6, 2019, to be closer to the family's home in Bowen, as "appropriate".
She said the decision to discharge the baby from MBH the first time was "finely balanced" and while medically sound, "perhaps placed an over-reliance on Daniel's parents' ability to care for him".
However, Ms Gallagher said that the decision to discharge the baby for a second time from MBH was not appropriate, based on his "ongoing failure to gain weight".
The deputy coroner said it was possible that alerting child safety earlier would have allowed time for an assessment of his parents' capacity to care for him and to engage in an intervention program to support his care.
Ms Gallagher said Daniel's parents' ability to care for him should have been considered more carefully by his treating practitioners and by child safety.
The deputy coroner noted medical records which showed both parents struggled to understand their responsibilities, and "needed constant prompting and correction".
The records also observed Mr Wright was "often aggressive, abusive, resistant to medical advice and dismissive of Daniel's needs".
She noted that child safety had determined an Intervention with Parental Agreement (IPA) as the most appropriate care plan, based on its judgement that the parents were willing to work with the department and keep the child's home safe.
The Mackay Hospital and Health Service (MHHS) submitted that doctors needed to "work within" the IPA unless Daniel's condition deteriorated so that his death was imminent.
In her findings, the deputy coroner said there was no single failing that would have changed the outcome for Daniel.
"Rather, there were a series of lost opportunities to share information about his case between the QH [Queensland Health] and Child Safety, combined with what was perhaps a global under-appreciation of Daniel's vulnerability and fragility," she said.
In submissions, the Townsville and Mackay Hospital and Health Services (MHHS) argued if there was no medical reason to keep the infant as an inpatient, and his parents wished to discharge him, there was no option to "compel a stay in hospital".
While the coroner described MHHS' home support for Daniel's parents as extensive, it was ultimately "inadequate".
Ms Gallagher also criticised child safety's response and said risk assessments did not adequately consider the risk of future harm to Daniel.
The inquest heard the hospital and health services, and child safety had since made changes in regard to information sharing across all government agencies.
"There are no practical recommendations which I could now make to prevent similar deaths in the future," she said.
