Inquest into the death of Jessica Agnes Poulson
[2018] NTLC 27
•26 November 2018
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, thereare 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.
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.
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.
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.
_________________________
GREG CAVANAGH
TERRITORY CORONER
[1] Letter from Dr Debbie Fearon dated 3 April 2017
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