BURTON-HO Anqelique File 2015-235464 Findings given by Mag Grahame DSC on 23-11-2018
Deceased
Angelique Burton-Ho
Demographics
12y, female
Date of death
2015-08-11
Finding date
2018-11-23
Cause of death
Cardio-respiratory failure due to aspiration pneumonia
AI-generated summary
Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening with oxygen saturation of 79% and admitted to the children's ward. Over 26 hours, her clinical deterioration was not recognized timely. A night-shift nurse initiated a clinical review at 1:15 am on 11 August but answered it herself without doctor involvement. No doctor reviewed her from 2:47 pm on 10 August until after 8 am on 11 August despite worsening symptoms and mother's concerns. Retrieval occurred only after Dr H.'s arrival. She died from cardio-respiratory failure due to aspiration pneumonia. The coroner found the death potentially preventable with earlier retrieval, and recommended improved escalation protocols, clinical review procedures with fresh eyes, and stronger REACH program implementation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to recognize rapid clinical deterioration in timely manner
- Inadequate initial triage and failure to see patient on first ED attendance
- Complacency based on previous recoveries from similar presentations
- Missed opportunity for early retrieval to tertiary hospital on 9 August evening
- Absence of medical review for 26+ hours despite progressive deterioration
- Night-shift nurse conducted clinical review herself without involving doctor
- Inadequate communication of clinical handover between doctors
- Failure to escalate mother's expressed concerns to senior medical staff
- Lack of planned monitoring and escalation thresholds for complex patient
- Extended period without oxygen support adjustment or blood gas monitoring
Coroner's recommendations
- SWSLHD introduce training programme for all paediatric nursing staff at Bowral and District Hospital on the Hospital's policy for paediatric respiratory support, including thresholds (6 litres per minute via Hudson mask, 2 litres per kilogram via heated humidified high-flow nasal cannula), requirement for paediatrician approval of oxygen changes, and minimum hourly observations for patients on respiratory support
- SWSLHD develop local Clinical Emergency Response System (CERS) protocol and paediatric specific CERS protocol as required by NSW Health Policy PD2013_049
- SWSLHD ensure CERS and paediatric CERS protocols specify that the designated responder for a clinical review cannot be the same person who initiated the clinical review (requirement for 'fresh set of eyes')
- SWSLHD conduct refresher training programme for all paediatric nursing staff at Bowral and District Hospital on REACH (Recognise, Engage, Act, Call, Help) program
- SWSLHD audit how REACH program is communicated to patients and families upon admission to Bowral and District Hospital, assess effectiveness, and consider displaying posters in patient rooms to raise awareness
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