CITATION:	Inquest into the death of Richard Ted Kunia [2016] NTLC 014

TITLE OF COURT:	Coroners Court

JURISDICTION:	Alice Springs

FILE NO(s):	A0004/2015

DELIVERED ON:	22 June 2016

DELIVERED AT:	Alice Springs

HEARING DATE(s):	22 June 2016

FINDING OF:	Judge Greg Cavanagh

CATCHWORDS: 	Death of child in care, expected death due to congenital serious medical conditions, appropriate care and treatment

REPRESENTATION:

Counsel Assisting:     	Kelvin Currie	

	

Judgment category classification: 	A
Judgement ID number: 	[2016] NTLC 014 
Number of paragraphs: 	20	
Number of pages: 	4	

IN THE CORONERS COURT
AT ALICE SPRINGS IN THE NORTHERN 
TERRITORY OF AUSTRALIA

No. A0004/2015
	In the matter of an Inquest into the death of 
	RICHARD TED KUNIA
	ON 29 JULY 2015
AT 18 WOOLLA COURT, ALICE SPRINGS

	FINDINGS

Judge Greg Cavanagh 
Introduction
1.	Richard Ted Kunia (the deceased) was an Aboriginal child, born 19 May 2009 at the Alice Springs Hospital to Thelma Fay Meneri of Areyonga and Rueben Kunia of Docker River.
2.	He was born with serious medical conditions including cerebral palsy, epilepsy, severe global development delay, recurrent aspiration syndrome, seizure disorder, renal tubular acidosis, microcephaly, spastic diplegia, deafness and blindness. At that time however, his most serious medical conditions were not known. He was however, known to be a “floppy baby”.
3.	The deceased came to the attention of the Department of Children and Families (DCF) on 31 December 2009 as he was failing to thrive and had frequent admissions to the Hospital.
4.	By February 2010 after consultation with the family, DCF removed the deceased from his family and on 19 February 2010 he was placed in foster care with Christine and Jonathon Pilbrow.  They had older children of their own and had been foster carers at that point for ten or eleven years caring for approximately twenty children during that period.
5.	At that stage, it was known that the deceased had sight and hearing issues and that he had epileptic seizures most days. He was nine months old.
6.	On 10 October 2012 the deceased was placed into the care of the Chief Executive Officer of DCF until the age of 18 years. From that date he was the subject of a Protection Order that wasn’t due to expire until 19 May 2027. He was subject to that Order until his death and was a “child in care”. An inquest into the circumstances of his death is mandatory pursuant to section 15(1)(a) of the Coroners Act.
7.	He stayed in the care of Christine and Jonathon Pilbrow until his death when six years of age. During that time the whole array of his serious medical conditions became clear. At approximately three years of age he was diagnosed with Cerebral Palsy, six months later he was fed through a nasal-gastric tube due to the problems of aspiration and at four years of age he had a PEG (percutaneous endoscopic gastrostomy) inserted through which he was fed directly to his stomach.
8.	Great care had to be taken to keep him from catching infections. Even the common cold and flu.
9.	His biological parents saw him whenever they wished. They were involved in the decision made relating to his Palliative Care arrangements including returning to his familiar surroundings at home toward the end of his life.
10.	The severity of the deceased’s medical conditions required constant and full-time support. At six years of age (the age at which he died) the deceased was wheelchair bound and unable to talk or eat.
11.	His medical files run to seven large volumes for the many treatments he received.
12.	Despite his difficulties he seemed generally to be a contented child. If he cried it was because he was in significant pain or distress.
13.	On 24 May 2015 he developed a high temperature and was breathing rapidly. He was taken to the hospital with viral pneumonia and increased seizure activity. He was admitted to the Intensive Care Unit the following day. He spent the next three weeks in the Intensive Care Unit and another five weeks in the Paediatric ward (from 16 June 2015). During that time his foster mother slept at the Hospital. 
14.	By July 2015 he was unable to breath without High Flow oxygen. There was no further treatment that was likely to benefit him. He was placed under the care of the Palliative Care Team from 13 July 2015.
15.	Multiple meetings were held with the medical specialists, DCF, the foster parents, his biological parents and the extended family. Many of the conversations were about the quality of his end of life. His parents and his foster carers preferred that he pass away in the familiar circumstances of his home rather than in the Hospital. 
16.	The decision was made to palliate him at home. 
17.	On 20 July 2015 he was discharged from Hospital on oxygen and supportive medications. The Hospital Palliative Care Team came to the house each day. His condition deteriorated over the next week. He was provided morphine to keep him comfortable.
18.	At 7.00 pm on 29 July 2015 his breathing slowed. He was in Christine’s arms at the time.  He died at 7.10 pm still in her arms.
19.	He was a much loved child. There is no doubt that his care and treatment were of an appropriate standard.
20.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was Richard Ted Kunia born on 19 May 2009, in Alice Springs, Northern Territory. 
(ii) 	The time of death was 7.10 pm on 29 July 2015. The place of death was 18 Woolla Court, Alice Springs in the Northern Territory. 
(iii) 	The cause of death was respiratory failure due to pneumonia. 
Other significant conditions contributing to death but not related to the condition causing death were severe global developmental delay, PEG feeds, epilepsy, microcephaly, spastic diplegia (making him wheelchair dependent), recurrent episodes of metabolic acidosis and recurrent lower respiratory tract infections.
(iv)  The particulars required to register the death are: 
1. 	The deceased was Richard Ted Kunia.
2. 	The deceased was of Aboriginal descent. 
3. 	The deceased was a child and not employed at the time of his death. 
4. 	The death was reported to the coroner by Alice Springs Hospital. 
5.	The cause of death was confirmed by Doctor Fariba Nadimi Specialist in Palliative Medicine. 
6. 	The deceased’s mother was Thelma Meneri and his father was Rueben Kunia.

Dated this 22 day of June 2016.
		_________________________
	JUDGE GREG CAVANAGH
                                                                             TERRITORY CORONER