Coronial
ACThospital

Inquest Into The Death Of Rozalia Spadafora

Deceased

Rozalia Spadafora

Demographics

5y, female

Coroner

Coroner Archer

Date of death

2022-07-05

Finding date

2024-12-06

Cause of death

myocarditis

AI-generated summary

A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Category 3 assignment but no medical review for 5 hours (required within 30 minutes); misinterpretation of an abnormal ECG by both the registrar and consultant paediatrician; lack of allocated responsibility for following up troponin test results; failure of ICU to properly assess the critically ill child despite consultation; inadequate handover processes with siloed information across departments; and excessive fluid administration straining the failing heart. By 0740 hours sufficient clinical evidence existed for myocarditis diagnosis (abnormal ECG, influenza A, hypotension, tachycardia, hepatomegaly). Earlier recognition and appropriate management including fluid restriction and timely NETS transfer might have provided a chance of survival with ECMO support in Sydney.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinepaediatricsintensive carecardiology

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

myocarditisfulminant myocarditisinfluenza A infectioncardiogenic shockcardiac failurepericarditisdehydrationhypotensiontachycardia

Procedures

ECGtroponin testingblood gas analysisintravenous fluid administrationintubationresuscitation

Contributing factors

  • delayed diagnosis of myocarditis by over 7 hours
  • misinterpretation of abnormal ECG
  • failure to follow up troponin results
  • excessive fluid administration to child with cardiac failure
  • inadequate ICU review despite consultation
  • failure to arrange early NETS transfer
  • siloed handover processes across departments
  • lack of clarity on clinical responsibility
  • inadequate paediatric staffing in ED and ICU
  • Clinical Initiatives Nurse position not rostered overnight

Coroner's recommendations

  1. CHS adopts a staffing model that ensures the Clinical Initiatives Nurse (CIN) position is filled on a 24-hour basis and quarantines the CIN position from the staffing demands of the ED
  2. Those involved in implementation of the new ICU and Paediatric ED, as well as planning of the paediatric Close Observation Unit, consider the evidence in this inquest and these findings
  3. CHS review the functionality of the Digital Health Records system in respect of handover processes, in light of the evidence given in this inquest
  4. CHS and ACT Health actively promote influenza vaccinations amongst children aged between 6 months and 5 years old
Full text
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