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Hail-Sage McClutchie - Source: Fairfax -
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A coroner has told the parents of a Waikato toddler that their failure to seek medical attention contributed to her death.
Hail-Sage McClutchie of Morrinsville was 22 months old when she died in September 2009 from head injuries suffered while in the care of her mother and her partner.
Sage had suffered several falls while playing at relatives'
houses and a local playground.
Coroner Peter Ryan says it is difficult to understand why the
couple did not take Sage to the doctor despite three days of
vomiting, loss of appetite and energy.
He has been unable to determine whether the girl's injuries were
accidental or deliberately inflicted, due to equivocal medical
evidence.
The coroner has also slated Child Youth and Family for failing to
assess Sage's safety even though the agency had taken her mother's
first child into care.
The coroner has recommended that Government agencies increase the sharing of information between each other so vulnerable children can be indenfitied early and their safety assessed and enhanced.
He has directed the recommendation to the Ministry of Social Development.
Social Development Minister Paula Bennett told TV ONE's Breakfast she hopes information sharing between agencies will prevent further such cases.
She said this will take changes to the Privacy Act.
"It will mean that we have to have a really good look at the checks and balances that we put in place. So what information are we sharing, on whom, who should know that we're sharing that information on them, how do we actually do that?"
Bennett said the Government needs to put "checks and balances" in place and that will be an important part of preventing such cases.
"I must say that information is shared very well a lot of the time. But it's not consistent, it's not across agencies and it's not with those non-government agencies like Plunket and others that do such a fantastic job."
The coroner has also recommended to the Families Commission that greater efforts be made to educate family members/ whanau on the need for them to monitor and support vulnerable children within the extended family.
'Absolute necessity' to seek help
Ryan said in findings released today that Sage's death highlights the absolute necessity for parents and caregivers of young children to seek medical assistance for children suffering an illness that does not quickly resolve.
Despite several days of vomiting and lethargy no medical attention was obtained for Sage. She subsequently suffered a seizure and was admitted to hospital in a critical condition, where staff were unable to prevent her death despite treatment.
Ryan said it is unacceptable that no medical attention would be obtained by day three or four of such symptoms in a 22-month-old child.
He said there were several opportunities missed by Sage's extended family members who had direct contact with her during the last few days of her life to insist on medical attention for her when she was clearly unwell.
"Any of these family members could have insisted that Sage be taken to the doctor, or they could have notified CYF of their concerns," Ryan said.
"If any good is to come from Sage's death, it must be that extended family members will realise their responsibility to support and assist vulnerable children within their own whanau."
Waikato Hospital paediatrician Dr Peter Herron had told the inquest that retinal haemorrhages were strongly indicative of Sage having been shaken and that this caused the haemorrhage which ultimately resulted in her death.
While the coroner could not determine whether Sage's injuries
were the result accidental or non-accidental trauma, he found the
failure by her mother and her partner to obtain medical attention
for her in the days leading up to her death was a contributing
factor in her death.
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