Inquest into the death of Bridgett CURRAH
Deceased
Bridgett Currah
Demographics
1y, female
Date of death
2013-05-22
Finding date
2017-03-16
Cause of death
aspiration of gastric contents due to recent gastroenteritis and vomiting leading to an exacerbation of gastro-oesophageal reflux disease (GORD) related vomiting
AI-generated summary
Bridgett Currah was a 19-month-old girl with complex medical needs including cyanotic congenital heart disease, gastro-oesophageal reflux, and feeding difficulties. She presented to Mildura Base Hospital on 21 May 2013 with gastroenteritis and vomiting, having lost approximately 700g over 36 hours. Clinical examination showed moderate dehydration with tachycardia, yet she was discharged the same evening after brief observation. The coroner found that standard hourly observations were not performed, blood tests were not obtained, and admission was not arranged despite her fragility and vulnerability. She died at home 9 hours later from aspiration of gastric contents. Clinicians should have admitted her for overnight observation given her comorbidities, objective evidence of moderate dehydration, recent acute illness, and the vulnerability of children with cyanotic heart disease to dehydration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to perform standard hourly observations during hospital admission
- failure to obtain blood tests despite objective evidence of moderate dehydration
- inadequate assessment of dehydration severity
- failure to admit patient for overnight observation
- discharge of vulnerable child in early evening with limited monitoring capability at home
- inadequate clinical record-keeping and review documentation
- failure to recognise cumulative clinical risk factors
Coroner's recommendations
- That nursing and medical staff at Mildura Base Hospital undergo education and training regarding the use of graphical observation and response charts and on the importance of taking and recording standard observations on them
- That Dr K. undergo education and training as to the importance of making an entry in the clinical notes for each occasion upon which a patient is reviewed and as to who has responsibility for making such entries
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