Inquest into the death Kyran DAY

Contributing factors

• Failure to diagnose ileocaecal intussusception with malrotation on initial assessment
• Premature diagnosis of simple gastroenteritis without excluding bowel obstruction
• Inadequate physical examination (Dr Greenacre did not examine Kyran's abdomen on first assessment on 19 October)
• Failure of nursing staff to escalate concerns about persistent vomiting despite nasogastric rehydration
• Failure to contact doctor overnight when patient developed tachycardia, ketonuria, and poor fluid tolerance
• Inadequate fluid management overnight and failure to recognize signs of dehydration
• Lack of abdominal imaging ordered by Dr Greenacre despite clinical features suggesting obstruction (vomiting without diarrhoea, lethargy)
• Ineffective communication of clinical urgency from doctor to nursing staff regarding ambulance booking
• Multiple people involved in ambulance booking chain diluted the sense of urgency
• Inappropriate response category assigned (R3 instead of R1) resulting in lower priority ambulance dispatch
• Delayed ambulance arrival (45 minutes after booking to reach hospital)
• Inadequate paramedic training and equipment for paediatric transport
• Delayed recognition of deterioration during ambulance transfer due to lack of continuous monitoring
• Delayed transfer to tertiary facility for definitive surgical intervention

Coroner's recommendations

1. That the New South Wales Minister for Health examine the policy and training programs activated by the ISLHD for paediatric resuscitation and deteriorating patient training and assessment, and give consideration as to whether similar policies should be implemented in other Local Health Districts in NSW. Advise the Coroner in writing by 30 June 2017.
2. That the NSW Ambulance Service advise the Coroner as soon as the Medical Priority Dispatch System (MPDS) Protocol 33 and Protocol 37 have been implemented. If implementation has not been completed by end of 2016, the Coroner be immediately advised and a timetable for implementation provided.
3. That the NSW Ambulance Service and NSW Department of Health give consideration to more effective ways in which the qualifications of paramedics and the categories employed by the Ambulance Service to delineate calls for assistance can be better communicated to all health professionals who may be required to book an ambulance or be involved in the booking process. The services be advised of any proposal (when finalised) or provide reason if recommendation is not implemented.