Coronial
NSWhospital

Inquest into the death of Bridgett CURRAH

Deceased

Bridgett Currah

Demographics

1y, female

Coroner

Decision ofDeputy State Coroner O'Sullivan

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. Report an inaccuracy.

Specialties

paediatricsemergency medicinecardiologygastroenterology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

omeprazoleranitidineparacetamolondansetron

Clinical conditions

cyanotic congenital heart disease with pulmonary atresiaventricular septal defectpulmonary artery stenosisgastro-oesophageal reflux diseaseglobal developmental delaycongenital glaucomafeeding difficultiesgastroenteritisdehydrationaspiration

Procedures

nasogastric tube placement

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

  1. 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
  2. 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
Full text
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