Deceased
Jasmine Lilian Cammilleri
Demographics
2y, female
Coroner
State Coroner Fogliani
Date of death
2013-02-11
Finding date
2016-12-28
Cause of death
chest injury - tear to right atrium with haemopericardium caused by television set falling on torso
AI-generated summary
A 2-year-old girl died from chest injury after a 15.8kg television set fell on her when she climbed onto an unsecured wooden cabinet. Despite prompt ambulance response and resuscitative efforts, she suffered a tear to the right atrium and haemopericardium. The death was preventable through television anchoring. Clinical lessons include: (1) understanding that children's flexible ribcages can sustain severe internal injury without external bruising, (2) recognizing that blunt chest trauma may cause arrhythmias and sudden cardiovascular collapse, and (3) emphasizing to families that unsecured heavy furniture and appliances pose serious hazards to curious toddlers. Public health education about furniture safety and anchoring systems is crucial for injury prevention.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Coroners Act, 1996 [Section 26(1)] Western Australia
RECORD OF INVESTIGATION INTO DEATH Ref No: 11/16 I, Rosalinda Vincenza Clorinda Fogliani, State Coroner, having investigated the death of Jasmine Lilian CAMMILLERI, with an Inquest held at Perth Coroner’s Court on 5 April 2016 find that the identity of the deceased person was Jasmine Lilian CAMMILLERI and that death occurred on 11 February 2013 at Fremantle Hospital Emergency Department, Alma Street Fremantle as a result of chest injury in the following circumstances - Counsel Appearing : Ms Kate Ellson assisted the State Coroner Table of Contents Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 1.
The deceased child Jasmine Lilian Cammilleri (Jasmine) was two years old when she died at the Emergency Department of Fremantle Hospital at approximately 1.08 pm on 11 February 2013, due to an injury to her chest caused by a television set falling on her.
The incident occurred in the family room of Jasmine’s home and she was quickly conveyed to Fremantle Hospital by ambulance.
Tragically despite prompt medical attention and resuscitative measures, Jasmine was unable to be revived.
Jasmine’s death was a reportable death within the meaning of s 3 of the Coroners Act 1996 (the Act) and it was reported to the coroner as required by s 17 of the Act. Pursuant to s 19(1) of the Act I have jurisdiction to investigate Jasmine’s death. The holding of an inquest was desirable, within the meaning of s 22(2) of the Act, in order to highlight the potential dangers of unsecured television sets in households were there are toddlers.
On 5 April 2016 I held an inquest into Jasmine’s death at the Coroner’s Court at Perth. I heard evidence from Mrs Cammilleri, Senior Constable Fiona Thorpe, the police officer attached to the Coronial Investigation Squad, and Dr Jodi White, Forensic Pathologist.
Jasmine was born on 31 August 2010 in Perth to Mrs Megan Cammilleri and Mr Jason Cammilleri. At the time of her birth she was the youngest of their three children. Her older brothers were eight and six at the time of her death.
Jasmine’s mother described her as very full of life, always happy and a joy to be around. She enjoyed playing with her brother’s toys and jumping on the trampoline. Her family loved her, she was achieving the normal milestones and she was thriving.
Jasmine had been a healthy child since birth and her general practitioner reported that she had attended the medical centre since six weeks of age being first seen on 12 October 2010 and last seen on 25 October 2012. She had the usual childhood colds and viruses and had only required antibiotics on one occasion. Her Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 2.
doctor noted that she had been well looked after and her immunisations were all up to date.1
Jasmine was inquisitive as is normal for children of that age. She also liked to climb things. Her mother recalled having to frequently lift her down from the change table and the kitchen bench. As a result Jasmine’s parents rearranged furniture so that she would not utilise the couch to climb onto the kitchen bench.
Jasmine was a very active child. Within reasonable parameters having regard to her age, she would watch some children’s programs on the family’s television set. Whilst she was too young to follow the programs, she was attracted by the moving images, colours and sounds. Her mother observed that when watching the programs, she wanted to be as close to the television set as possible.
A few months before her death Jasmine had started climbing up onto the wooden cabinet where the television set was located. The cabinet was approximately 650 millimetres high. Jasmine would use her hands to push herself up and would then place her feet where the DVD player was, or on the cabinet’s shelves, as leverage, to climb on top of the cabinet. Her mother had seen her do that on close to a dozen occasions.
On occasion Mrs Cammilleri had also observed Jasmine touch the television set, or hang over the top of it, once she had climbed onto the cabinet.
Mrs Cammilleri was consistent in warning Jasmine about the dangers of climbing onto the cabinet, encouraging her not to do it, and lifting her down every time she saw her on the cabinet. A few days before Jasmine’s death, she pushed the television set back along the cabinet because she thought it may be of less interest to Jasmine if the screen was further away. Whilst Mrs Cammilleri’s intention had been to make it safer for Jasmine, in retrospect it may have ended up creating a space in front of the television set, with enough room for Jasmine to climb on.
1 Exhibit 1, Tab 9 Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 3.
Mrs Cammilleri had left Jasmine standing in front of the television set while she briefly went into another room to make a telephone call and check an email on her computer. The telephone call lasted approximately five minutes. Mrs Cammilleri was not out of the room for very long at all, but toddlers will move around very quickly. One moment, Jasmine was standing in front of the television set, and moments later, while her mother was out of the room, Jasmine appears to have climbed up on top of the cabinet, with the likely intention of getting closer to the television set as she had done on a number of previous occasions.
From the other room Mrs Cammilleri heard Jasmine cry out and then heard a loud bang. She rushed to the family room and found Jasmine lying on her back on the tiled floor with the television on top of her. The screen was face up and across Jasmine’s legs. The base of the television set was on Jasmine’s torso. Jasmine’s feet were pointing towards the cabinet, indicating that she had fallen backwards.
Mrs Cammilleri immediately retrieved her daughter from under the television set and contacted St John Ambulance. She saw that Jasmine had turned blue, and then went pale and was having trouble breathing. Mrs Cammilleri recalled there were big pauses in between her breaths.
Records reflect that the St John Ambulance call was received at 11.24 am on 11 February 2013 and that the ambulance departed within approximately one minute under priority 1 conditions arriving at Jasmine’s home at 11.35 am.2
Upon arrival the ambulance paramedics found Jasmine lying on her left lateral side on the sofa, in accordance with the instructions that Mrs Cammilleri had been given over the telephone by the St John Ambulance operator. The paramedics found Jasmine to be unresponsive, pale, with cyanosis to the lips and with cool extremities. No pulse was detected.
Ambulance paramedics immediately commenced CPR. Within a couple of minutes, a carotid pulse of 130bpm was detected and ECG showed a normal sinus rhythm. The paramedics assisted with Jasmine’s ventilation and conveyed her to the Emergency Department of Fremantle Hospital, arriving at 12.20 pm on 11 February 2013.
The emergency team were aware that Jasmine did cry on route to Fremantle Hospital. On examination in the Emergency Department, Jasmine’s airway was initially intact when she was 2 Exhibit 1, Tab 7 Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 4.
lying on her side, but appeared to partially obstruct when she was placed on her back. There was bi-lateral air entry in the lungs and there were no external signs of a chest injury.
In the Emergency Department, Jasmine’s oxygen saturation was recorded as 100% on 100% oxygen. Her pulse rate was 140bpm and her blood pressure was 85 systolic mmHg. She appeared slightly pale and there was no obvious bleeding. She was crying and although she was moving all limbs she appeared floppy. Her pupils were bilaterally dilated. She was bleeding from the lip but there were no other signs of injury. There was an initial concern about possible internal injury.
Jasmine was intubated so that a CT scan could be undertaken but soon afterwards she developed bradycardia, (an abnormally slow heart rate of 45bpm) and became hypotensive with loss of all palpable pulses. The emergency team immediately commenced CPR and she was given medications and a fluid bolus. There was no response and CPR was continued. All reversible causes of hypotension were excluded.
Despite prolonged resuscitation there was no return of spontaneous circulation, no palpable pulses, no breath sounds and no movement or responses. The emergency team discontinued CPR and tragically Jasmine was pronounced dead at 1.08 pm on 11 February 2013.
On 13 February 2013 forensic pathologist Dr J White made a post mortem examination on the body of Jasmine at the State Mortuary. At the conclusion of the examination Dr White was unable to determine a cause of death and further investigations were undertaken including neuropathology to exclude a head injury, toxicology and histology.3
There was no external evidence of recent injury to the bones of the limbs and there was no bruising of the soft tissues of the anterior chest or abdominal walls. Dr White found a tear to the right atrium with a haemopericardium.
Upon examination of the brain, specialist neuropathologist, Dr V Fabian found no significant abnormalities and no macroscopic features of a head injury.4 3 Exhibit 1, Tab 10 4 Exhibit 1, Tab 11 Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 5.
Toxicological analysis showed medications post mortem consistent with Jasmine’s care.5
After the further investigations, on 13 August 2013, Dr White formed the opinion that the cause of death was chest injury.
At the inquest Dr White addressed the reasons for there being no external evidence of recent injury, nor bruising of the chest, despite the fall of the television set on Jasmine’s torso. She explained that children have quite flexible ribcages because the chest area is quite cartilaginous. The sudden and forceful drop of the television set would have pushed her chest in and ultimately resulted in the tear at the top of the heart. Further, the blow to that area can also disturb the heart muscle, leading to abnormal heart rhythms.6
On all of the evidence before me I am satisfied that Jasmine climbed on top of the wooden cabinet and most likely positioned herself in front of the television set. She then either lost her balance, causing her to take hold of the television set in reaction as she fell backwards towards the floor, or otherwise the television set became unstable by her touching it in such a manner as to cause it to move, and fall.
When Mrs Cammilleri came to Jasmine’s aid, the television set’s screen was facing upwards. As it fell, it may have angled down on the edge of the cabinet, causing it to topple again over itself and land on Jasmine who had fallen to the floor on her back. No other person saw this happen. Jasmine’s mother was close by and heard her scream out.
Jasmine weighed approximately 21 kilograms and was 80 centimetres in height. She would not have been able to reach and pull the television set down by standing next to the cabinet.
I accept Dr White’s opinion and find that the cause of Jasmine’s death was chest injury.
purchased new from the store in 2010, when Jasmine was about three months old. It weighed 15.8 kilograms. The heaviest part was at the base, being the part that impacted upon Jasmine’s torso.7
Both Mr and Mrs Cammilleri spoke with the salesperson when they purchased the television set, though Mrs Cammilleri was primarily attending to the children. She did recall the salesperson talking about the brackets, in order to affix (or bracket) the television set onto the wall. The salesperson had also mentioned the possible use of safety straps to Mr Cammilleri.8
Mrs Cammilleri thought that the salesperson raised the option of bracketing the television set onto the wall for reasons of aesthetics. She did not apprehend that the salesperson was raising it as a safety consideration. Mr and Mrs Cammilleri decided to postpone the bracketing of the television set to the wall, and revisit it at a later stage in connection with a planned repainting of the wall.9 They placed the television set, on its base, on the wooden cabinet. It was not secured to the wooden cabinet or the wall behind it.
The television set came in a box with an instruction booklet entitled: “Owner’s Manual”.10 The booklet is quite lengthy (47 pages). Mrs Cammilleri did not read the instruction booklet, and did not recall her husband reading it either.
The instruction booklet contains a summary of safety instructions on the first page. It includes a caution in the following terms: “Install the product on a flat and stable place that has no risk of dropping the product. If the product is dropped, you may be injured or the product may be broken.”11
This particular television set was designed to be installed in various ways, such as on a desktop, or on a wall, mounted horizontally. Desktop pedestal installation, the option chosen by Mr and Mrs Cammilleri, simply required a clearance of 10cm all around the television set, for adequate ventilation.
set’s base establish that there were no holes at the back of the base such as would have enabled the anchoring of the television set to the cabinet with a screw.12
The following comment is made: “The instructions shown below are a safer way to set up the TV, by fixing it to the wall, avoiding the possibility of it falling forwards if pulled. This will prevent the TV from falling forward and causing injury. This will also prevent the TV from damage. Ensure that children do not climb or hang from TV.”13
The instructions that deal with attaching the television set to a wall appear at page 27. They recommend the use of a VESA14 compliant LG Brand wall mounting bracket, and that wall mounting be performed by a qualified installer.
At the inquest I received into evidence information about a range of other recommended products, referred to as anti-tip TV anchoring systems, which are available for purchase. They include various types of straps to help prevent a television set from tipping and slipping. The products are marketed with parents of young children in mind, and contain the obvious warning that the products are not a replacement for direct adult supervision.15
At the inquest I also received into evidence the Australian and New Zealand Standard for safety requirements for audio, video and similar electronic apparatus (AS/NZS 60065:2012).16 The Standard would apply to the television set that Mr and Mrs Cammilleri had purchased. The application of the Standard is intended to prevent injury or damage due to electric shock, excessive temperatures, radiation, implosion, mechanical hazards and fire.
Under the heading mechanical hazards in the introductory section, it is stated that requirements are included to ensure the apparatus and its parts have, amongst other things, adequate mechanical strength and stability. Paragraph 3.1 of the Standards requires that the apparatus be so designed and constructed as to present no danger when used for its intended purpose, and to 12 Exhibit 3 13 Exhibit 1, Tab 15 14 Video Electronics Standards Association 15 Exhibit 2 16 Exhibit 1, Tab 16 Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 8.
particularly provide protection against a range of matters including mechanical instability.
Under Part 12 of the Standards, dealing with mechanical strength, paragraph 12.1 requires that: “The apparatus shall have adequate mechanical strength and be so constructed as to withstand such handling as may be expected during intended use”.
Under Part 19 of the Standards, dealing with stability and mechanical hazards, there is a requirement for apparatus (such as television sets) with a mass of 7kg or more to have adequate stability. Under the related Appendix ZZ of the Standards, such television sets are required to have “additional stability”. The information in the instructions for installation or use for such television sets ought to contain the following, or similar:
IMPORTANT INFORMATION If a television is not positioned in a sufficiently stable location, it can be potentially hazardous due to falling. Many injuries, particularly to children, can be avoided by taking simple precautions such as:
• Using cabinets or stands recommended by the manufacturer of the television.
• Only using furniture that can safely support the television.
• Ensuring the television is not overhanging the edge of the supporting furniture.
• Not placing the television on tall furniture (for example, cupboards or bookcases) without anchoring both the furniture and the television to a suitable support.
• Not standing the television on cloth or other materials placed between the television and supporting furniture.
• Educating children about the dangers of climbing on furniture to reach the television or its controls.
Such information should also be provided as a label on the apparatus.
Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 9.
Paragraph 19.201.2.2 of Appendix ZZ to the Standards addresses restraining devices for television sets, such as a fixing point, and recommends their usage to restrain the television set from toppling forward.
I am satisfied that the Standards adequately address the potential hazard of a television set toppling over onto a child, and that the contents of the instruction booklet for Mr and Mrs Cammilleri’s television set were adequate.
Desktop installation of television sets with no anchoring point is common. It is one of the options. However, I have no doubt that if Mr and Mrs Cammilleri had apprehended the risk, they would not have hesitated to anchor the television set to a point.
Pursuant to s 25(2) of the Act, I may comment on any matter connected with Jasmine’s death, including public safety.
Jasmine’s death was preventable. The inquest was held in the hope of drawing the public’s attention to the potential risk posed to a young child of a television set becoming unstable and toppling over. Most parents will have experienced a young child’s attraction to the moving images, but with television sets becoming flatter and lighter, the risk of them falling in the vicinity of a child, and the damage they can do, may not be apprehended.
Whilst anchoring a television set to a fixed point does not replace direct adult supervision in the case of young children, it is a safety measure that ought to be pursued. Mrs Cammilleri felt that there was insufficient emphasis placed upon the safety features when she and her husband purchased the television set.
With that in mind, a copy of this finding will be made available to KidSafe WA, the child accident prevention foundation. It will enable KidSafe WA to tailor their key messages on furniture safety on their facts sheets, publications, workshops and seminars to be consistent with these findings. In doing so, I take into account their policy of de-identifying injury prevention messages.
KidSafe WA currently has approximately 110,000 website visits per year and approximately 15,000 face to face contacts with children, parents, carers, health professionals and teachers. They are uniquely placed to alert carers of young children to potential hazards, and through their networks, to advocate for injury prevention and updates to furniture standards.
Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 10.
Jasmine had been known to climb the wooden cabinet in the family room of her home to get closer to the television set that was placed upon it. On 11 February 2013 while her mother was temporarily out of the room, Jasmine climbed on top of the wooden cabinet, and then fell backwards to the floor, with the television set also falling, and landing on top of her. As a result she sustained a fatal injury to her chest.
Jasmine was dearly loved by her family and her tragic death came as an unexpected shock. Mrs Cammilleri was keen for other parents to understand the risks posed by an unsecured television set in similar circumstances. It is my hope that by highlighting the risks in the inquest, parents of young children are encouraged give serious consideration to anchoring television sets by an approved means, and that these findings provide KidSafe WA with information from which they may draw safety messages for parents and prospective parents.
R V C FOGLIANI STATE CORONER 28 December 2016 Inquest into the death of Jasmine Lilian CAMMILLERI (173-13) page 11.
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