A “tragic accident” which killed a toddler has led a coroner to propose an awareness campaign about e-cigarette liquids
The child, identified only as “Baby J” in court documents, died on 10 June 2018.
Baby J was 18 months old at the time of his death, and lived with his parents.
On the evening of 30 May 2018, Baby J’s mother was in the dining room of the home with her baby, and was syringing high-concentration liquid nicotine into bottles of vape juice for use in e-cigarettes.
Both the baby’s mother and father were using the devices in a bid to quit smoking.
As noted by Coroner Phillip Byrne, the liquid nicotine they were using is not approved for use in Australia, and had been purchased online from the USA some time earlier.
In March 2017 the TGA had handed down a final decision on nicotine: to maintain the ban on the substance for use in e-cigarettes, following an application to exempt these liquids (containing low concentrations of the active) from the Poisons Schedule.
“Baby J’s mother left the open bottle of liquid nicotine on the bench and turned to put the vape juice bottles she had prepared on the bookshelf,” Coroner Byrne noted.
“She looked back to see Baby J had reached up, taken the opened bottle and put it into his mouth.
“He had consumed an unknown amount of the highly toxic liquid.”
Baby J’s mother reacted quickly, he observed, rushing the boy to the bathroom and washing his mouth out, and then calling 000.
As she dialled the number, he became limp, and bubbles came from his mouth.
Emergency services responded in a timely manner and observed that the boy was in cardiac arrest; they managed to achieve a return of spontaneous circulation, and the baby was hospitalised.
However a CT scan performed on 2 June showed generalised diffuse cerebral oedema, and an MRI study performed on 4 June showed changes consistent with “profound irreversible global hypoxic ischemia brain injury”.
The family, in conjunction with the treating doctor, decided to withdraw life support on 10 June, and Baby J died within two hours in the arms of his parents.
Coroner Byrne was satisfied that Baby J’s death was related directly to the ingestion of concentrated nicotine liquid.
A report from the Victorian Paediatric Medical Service for Victoria Police and the Department of Health and Human Services found that while Baby J’s mother “undoubtedly” placed him at risk by leaving the open bottle of nicotine liquid for a moment while she turned away, this did not constitute supervisory neglect, but a “momentary lapse in vigilance”.
The coroner agreed with this assessment, saying the incident could reasonably be classified as a momentary lapse in vigilance, rather than “supervisory neglect”.
He noted that Baby J’s death had caused his mother “unimaginable” grief and severely impacted her mental and psychological wellbeing.
Coroner Byrne noted that the main rationale for an inquest hearing into Baby J’s death was to “bring the issue into the public domain with the prospect I would consider making a formal recommendation that the Department of Health and Human Services consider conducting a public awareness campaign on the issue in the interest of the public health and safety”.
He instructed a coroner’s solicitor to get in touch with Safer Care Victoria, which through Professor Euan Wallace maintained opposition to legalising nicotine-containing vapid liquids in Australia.
A key reason was that in the context of Baby J’s death, widening the availability of such liquids in Australia would increase the likelihood of accidental ingestion by children, Prof Wallace said in his response.
“I see a conundrum; if the product is banned in Australia, how can we in this country enforce safeguards like tamper-proof packaging of a product manufactured overseas and accessed online illegally,” Coroner Byrne observed.
He noted that work is already being done in Victoria to alert consumers of the risks of using e-cigarettes around children.
However, he also proposed a public awareness campaign.
“At first blush, the legalisation in Australia of liquid nicotine for use in vaping liquid has a logical attraction if it enables regulation of content and safeguard packaging,” he said in handing down his findings.
“However, with claim and counterclaim the issues are far more complex, indeed controversial, than I initially thought.
“To buy into this debate would be akin to sailing into a maelstrom. Consequently, I am not prepared to make any recommendation that would alter the status quo.”
He found that Baby J’s death was due to a “tragic accident”.