Nikolas Clarke acts for local authority in inquest into toddler’s death

28 June 2024

Nikolas Clarke acted for the local authority in an inquest into the death of DF, a 21-month-old child. DF died in hospital of respiratory failure and cardiac arrest.

The local authority had had a care order in place concerning DF and his twin.  (They had been born to parents who were serious drug users).

Background to the inquest

The twins had been born prematurely in April 2022.

DF had a serious heart condition and required ongoing respiratory support. He underwent heart surgery and was fitted with a tracheostomy in August 2022.

A few months later, he was moved from paediatric intensive care and placed on a long-term ventilator in a general children’s ward.

In July 2023, DF suffered a cardiac arrest while on the ward after his tracheostomy became inadvertently dislodged. He suffered a significant brain injury as a result.

An application to the High Court for his treatment to be reoriented to palliative care was granted in January 2024.

DF was disconnected from his ventilator and died in February 2024.

The inquest

At the 1-day inquest, Nikolas argued that Article 2 ECHR was engaged as:

  • the hospital failed to have a risk assessment tool in place
  • there had been no robust planning for DF’s discharge from critical care to a general ward
  • the real and immediate risk to DF’s life if he were without his tracheostomy for any period of time ought to have been known by the hospital.
Coroner’s conclusion

The coroner decided to proceed with the scope of the inquest -including Article 2 – being kept under check throughout the hearing.

However, he concluded that:

  • Article 2 was not engaged, and
  • there was no gross failure on the evidence heard to consider neglect.

He made a narrative conclusion that DF died as a result of injuries sustained during a cardiac arrest following the inadvertent dislodgement of his tracheostomy.