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CORONERS ACT, 2003

SOUTHAUSTRALIA

FINDING OF INQUEST

An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide and Port Augusta in the State of South Australia, on the 8th, 27th, 28th, 29th and 30th days of August 2012 and the 18th day of April 2013, by the Coroner’s Court of the said State, constituted of , , into the death of Olivia Jean Johnson.

The said Court finds that Olivia Jean Johnsonaged 11months, late of Balcanoona Road, Balcanoona via Copley, South Australia died at Balcanoona via Copley, South Australia on the 30th day of May 2011 as a result of dehydration. The said Court finds that the circumstances of were as follows:

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  1. Introduction
  2. Olivia Jean Johnson, who was born on 15 June 2010, died on 30 May 2011, being only a fortnight away from her first birthday.
  3. Olivia was the younger of two children of Melissa Hands and her partner, Wade Johnson, both of whom are indigenous people. The other child of Ms Hands and Mr Johnson is Oshay, a boy, who at the time of these events was nearly 2 years of age. Olivia lived with her parents and her sibling on the Balcanoona Station where Mr Johnson was a construction and maintenance worker[1]. Balcanoona Station is 105 kilometres[2] from Leigh Creek in the north of the State. Leigh Creek is the closest centre with medical services. Although the distance that I have just quoted is not in and of itself huge, the road between Balcanoona Station and Leigh Creek leaves something to be desired and a vehicular journey between the two locations can take as long as 2 hours.
  4. Olivia died at the family home at Balcanoona Station on the evening of Monday 30 May 2011 despite frantic efforts on the part of her parents and others to resuscitate her after her collapse from what at autopsy was undoubtedly established as dehydration.
  5. During the course of this Inquest I heard oral evidence from both Ms Hands and Mr Johnson. I state at the outset of these findings that Olivia’s death was not due to any neglect or fault on the part of her parents. That Olivia would succumb to dehydration was the result of her suffering from an acute gastric disorder that involved a number of bouts of vomiting and diarrhoea for which her parents sought medical treatment. As expressed in the post-mortem report[3] prepared by Dr Karen Heath, a forensic pathologist at Forensic Science South Australia, it is entirely possible for an infant to become critically dehydrated within a very short period of time, hours, in the setting of vomiting and diarrhoea. Dr Heath also suggests in the report that in Olivia’s case the vomiting and diarrhoea could account for the child’s dehydration. For my part the matter appears to be beyond any doubt at all. There is no other explanation for the infant becoming so profoundly dehydrated. I find the cause of Olivia’s death to have been dehydration.
  6. The evidence also demonstrated that Olivia had experienced what is known as hypernatraemic dehydration where due to the dilution of the fluid lost from the body by way of vomiting and diarrhoea, especially from copious vomiting, the concentration of sodium within the tissues increases. In Olivia’s case this is evident from the fact that at autopsy she had a marked elevated vitreous sodium level of 171mmol/L. Such a diagnosis in the living patient would lead to a regime of rehydration management than might differ from that associated with conventional dehydration. In addition, the high sodium level might give rise to differing symptomatology such that abnormal skin turgor, an important diagnostic tool usually associated with conventional dehydration greater than 5%, might not be apparent.
  7. Earlier on the day of her death, Olivia’s parents had made the journey from Balcanoona Station to Leigh Creek by 4WD and had attended at the Leigh Creek Hospital and Medical Clinic where Olivia was examined by Dr Geoffrey Cox, a medical practitioner. Ms Hands had specifically raised with Dr Cox her concerns about the possibility of dehydration but in effect had been assured that at that point in time Olivia was not dehydrated. Indeed, Ms Hands had been so concerned about Olivia to the point where she had fully expected Olivia to be sent to Port Augusta to be seen by the local paediatrician there. Although admission to the local Leigh Creek Hospital would have been another option, in the event Ms Hands was allowed to take Olivia homewith advice to keep her fluids up and to bring her back if the diarrhoea persisted. Ms Hands was also provided with Gastrolyte, a rehydrating agent. Ms Hands and Mr Johnson then took Olivia home to Balcanoona Station where that evening she died. As a measure of the difficulty associated with the remoteness of the location, it took police and an ambulance some 109 minutes[4] to travel from Leigh Creek to Balcanoona Station during which time Olivia was constantly administered CPR. Olivia was certified deceased by ambulance officers very soon after their arrival.
  8. The evidence is that Olivia’s death probably could have been prevented if she had been kept at Leigh Creek and been observed at the local hospital. Although in all probability she would ultimately have required retrieval to a hospital that could have provided a greater level of care, with earlier identification of her dehydration and the necessary corrective treatment there is every reason to believe that she could have survived. The Inquest raised important issues as to the type of advice and medical response that ought to be given and implemented in cases where a person, particularly an infant in these circumstances, is discharged knowingly to a remote location at which further more urgent medical intervention may simply not be possible.
  9. Olivia’s wellbeing before her consultation with Dr Cox
  10. There was some evidence adduced in respect of Olivia’s previous medical history that was relevant in one aspect. Olivia had been born 7 weeks prematurely and in addition had suffered from a hernia that had required surgery. Ms Hands told the Court that medical advice at the time had suggested that upon attaining the age of 1 year,Olivia would have reached a milestone in terms of her wellbeing and survivability, particularly in relation to her lung development. Ms Hands told the Court that she had been led to believe by doctors that Olivia’s survival in the first instance had been something of a miracle. In the first year of her life, Olivia was periodically seen by Dr Han, the paediatrician at Port Augusta. She had travelled to Port Augusta from Balcanoona Station on those occasions. That Olivia had progressed to a state of satisfactory health at the age of 11 months was a matter in which Ms Hands took obvious pride. Ms Hands also has experience in working in Aboriginal infant health care. This is all relevant to demonstrate that Ms Hands took the health of her daughter extremely seriously and it led me to the conclusion that when Ms Hands described in evidence features of her daughter’s presentation at the time with which this Inquest is concerned, she did so with a relatively high degree of accuracy. Furthermore, and having seen Ms Hands give oral evidence, it occurred to me as being highly likely that Ms Hands would not have been reticent in expressing whatever concerns she had in respect of her daughter to a medical practitioner.
  11. Ms Hands provided a statement[5] to one of the police officers who on the night in question had attended at their premises at Balcanoona Station. Ms Hands had signed that statement in the police officer’s notebook. In that statement Ms Hands said that Olivia’s gastro and vomiting had started the previous night. At 6am the following day Ms Hands and her partner had heard Olivia vomit in her cot which they positioned in their bedroom. Although Olivia appeared to be happy and was mobile shortly after that event, she was not herself. In this initial statement Ms Hands indicated to the officer that in the morning Olivia’s eyes had ‘looked dark and slightly sunken in’[6]. In addition Ms Hands described Olivia as appearing exhausted. She had a loose nappy with mustard colour watery faeces. Ms Hands indicated that at that point she thought Olivia had been dehydrated. Ms Hands described another nappy change at Nepabunna on the way to Leigh Creek. They were the salient features of Ms Hands’ description, as contained in her statement, of Olivia’s wellbeing prior to her being seen by Dr Cox. It is of note that she stated that in the morning Olivia’s eyes had looked dark and slightly sunken in, which is a sign of some significance when her presentation to Dr Cox, and the possibility that dehydration was already in play at that time, come to be evaluated.
  12. Ms Hands made a further statement to police[7]on 21 July 2011 that dealt in some detail with Olivia’s previous medical history, but did not elaborate upon her description of Olivia’s presentation on the day in question.
  13. Ms Hands gave oral evidence at the Inquest. In her oral evidence before the Court Ms Hands provided greater detail in relation to Olivia’s condition in the 48 hours prior to her death. On the Sunday afternoon, 29 May 2011, Olivia had what Ms Hands described as a ‘power chuck’[8]. This was her term for what must have been an episode of projectile vomiting. By that time Ms Hands had already changed Olivia’s nappy twice for diarrhoea. Ms Hands described the diarrhoea as very watery and so it would not be possible to determine over the next 24 hours or so to what level of frequency or volume the child had been urinating. Ms Hands suggested that the time at which the episode of vomiting had occurred was shortly before 3:30pm or 4pm when she bathed the child. Ms Hands told the Court that Olivia was quite happy for the rest of the day, but that the diarrhoea persisted such that Ms Hands had to change her frequently throughout the rest of the day and night. She took her bottles of formula every 3 hours. That evening Ms Hands and her partner resolved that if Olivia did not improve they would take her to the doctor the following day. Ms Hands’ description of the time at which Olivia’s difficulties with vomiting and diarrhoea commenced differed from that given in her original statement taken on the night of Olivia’s death insofar as the statement suggested that those difficulties had commenced the previous night as distinct from during the day. It is apparent that the statement was given at a time when the stress and grief associated with Olivia’s death must have been profound. Furthermore, not surprisingly, the statement speaks for the most part in generalities and not with the precision one might expect after careful reflection. Her oral evidence is also not inconsistent with other evidence in the case. While Dr Cox would tell the Court that he recalled being told by Ms Hands that Olivia had started vomiting the evening before and had developed diarrhoea the evening before[9], he noted in the clinical record[10] that Olivia had started diarrhoea and vomiting ‘yesterday’. I accept Ms Hands’ oral evidence where it differs from her statement. I accept Ms Hands’ oral evidence that the vomiting and diarrhoea had started during the afternoon of Sunday 29 May.
  14. During the night Ms Hands was aware that her partner had arisen to give Olivia a bottle.
  15. The next observation of Olivia was the following morning when Olivia vomited in her cot at around 6am. She was cleaned up and it was also evident that Olivia was still experiencing diarrhoea. Ms Hands did not believe that Olivia had a bottle that morning. She did not appear to want it. It was then that Ms Hands examined Olivia and concluded that she was not herself. In this regard Ms Hands told the Court that Olivia had dark rings underneath her eyes and was exhausted. Ms Hands was concerned that she was dehydrating. Importantly, she had never seen Olivia’s eyes in that condition prior to this occasion[11].
  16. Ms Hands and Olivia’s father decided that they would take her to Leigh Creek out of concern that the diarrhoea was causing Olivia to dehydrate. Ms Hands packed a bag with things for Olivia and herself in case they were sent to Port Augusta. This decision was made before 8am, as they left the house at about that time. Ms Hands believed that they had to change another nappy prior to leaving.
  17. Wade Johnson’s parents resided at a place called Nepabunna which is on the road between Balcanoona and Leigh Creek. They stopped there to tell Mr Johnson’s parents of their intentions. Ms Hands believed that they changed Olivia again at Nepabunna. By that stage Olivia looked tired and was still dark around her eyes.
  18. Ms Hands believed that they changed Olivia at least three times on the way to Leigh Creek[12].
  19. Ms Hands stated that from the Sunday afternoon until arriving at Leigh Creek she had changed Olivia on approximately 8 occasions, on each of which it was evident that Olivia had experienced diarrhoea. All this was naturally out of the ordinary in terms of frequency. Later in her evidence Ms Hands told the Court that she believed that she had changed the child on at least 10 occasions during that same period. On each of those occasions Ms Hands’ said the bowel actions had been loose and had been wet such that she could not tell whether the child had urinated. In any event it is clear that the child had lost a lot of fluid, although she had been drinking[13]. I accept Ms Hand’s oral evidence that she had changed Olivia’s nappy on at least 8 occasions.
  20. Ms Hands also believed that during the consultation with Dr Cox at Leigh Creek she changed the nappy again and the contents were the same as before with watery diarrhoea. In her evidence Ms Hands stated that she was sure that Dr Cox had seen the contents of the nappy. However, in cross-examination Ms Hands indicated that she was not completely certain that the nappy had been changed during Dr Cox’s consultation[14].
  21. The appearance of Olivia’s eyes at the time of the consultation is of some significance as sunken eyes are a sign of possible dehydration. Ms Hands testified that at the time of Dr Cox’s examination Olivia still had dark rings under her eyes. Ms Hands did say that later that same day, after they had returned from Leigh Creek to Balcanoona Station, the dark rings associated with Olivia’s eyes looked darker than what they had during the morning and were more sunken in[15]. In cross-examination by Mr Homburg, counsel for Dr Cox, Ms Hands stated that in the morning Olivia’s eyes had not appeared to be sunken although they were dark underneath[16]. She agreed with cross-examining counsel that the obvious sunken appearance of the eyes did not emerge until the Monday afternoon after they had returned from Leigh Creek[17]. On the topic of when it was for the first time that Olivia’s eyes had appeared sunken, it will be remembered that Ms Hands’ original statement suggested thatOlivia’s eyes had been slightly sunken during the morning before they left for Leigh Creek. In addition, as will be seen, Dr Cox would state in his evidence before the Court that during the examination at Leigh Creek Ms Hands had specifically asked him whether he thought her Olivia’s eyes were sunken at that point in time. To my mind it is clear that at the time of the examination there was something unusual and not right about the state of Olivia’s eyes and that this was a source of legitimate concern on the part of her mother. The objective evidence is that when Olivia was examined after death, her eyes could be described as sunken.
  22. The other salient feature of Olivia’s presentation as described by her mother was that she had been lethargic which by comparison to her usual energetic behaviour was out of character. She stated that she pointed that fact out to Dr Cox during the consultation. I will deal with the events of that consultation in another section of these findings.
  23. Olivia’s father, Wade Johnson, also provided the police with a statement on the night of Olivia’s death. This statement was recorded by hand in an officer’s notebook[18]. The officer in question was Senior Constable First Class Kym Mayger whose statement[19] records that he read the statement to Mr Johnson who then signed it. Mr Johnson also gave oral evidence at the Inquest but many of his answers evinced a less than perfect memory as to detail. To my mind, however, Mr Johnson was an honest witness who did his best to describe relevant matters. My discussion of Mr Johnson’s evidence is confined to his account of Olivia’s presentation prior to the visit to Dr Cox’s practice in Leigh Creek. Mr Johnson’s handwritten statement is consistent with his partner’s evidence that Olivia had started to experience diarrhoea the day before.