Inquest into the death of Shaun BELL
Deceased
Shaun Bell
Demographics
4y, male
Date of death
2016-03-14
Finding date
2019-05-14
Cause of death
Peritoneal sepsis caused by a perforated duodenal ulcer
AI-generated summary
A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglobin (61 g/L), very low sodium (114 mmol/L), elevated white cell count, and persistent tachycardia. Critical clinical lessons: (1) multiple clinicians failed to appreciate how critically unwell he was, resulting in failure to escalate care urgently; (2) a junior registrar inappropriately altered SPOC calling criteria without consultant discussion; (3) a provisional viral gastroenteritis diagnosis was inadequately reconsidered despite accumulating abnormal pathology; (4) the daytime team did not perform fresh assessment of the clinical picture but were influenced by preceding teams' reassurance; (5) tele-triage nurses lacked specific training in assessing non-verbal developmentally delayed children for serious pathology. A collective 'group think' failure meant the combination of findings that should have triggered immediate escalation and higher-level investigation was missed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to recognise critical illness across multiple clinicians
- Inadequate differential diagnosis formulation
- Collective 'group think' phenomenon leading to endorsement of provisional diagnosis without re-evaluation
- Inappropriate modification of SPOC calling criteria without consultant discussion
- Insufficient proactive escalation despite accumulating abnormal results
- Lack of specialist paediatrician bedside review despite critical indicators
- Inadequate hand-over communication of urgency to incoming teams
- Daytime registrar did not perform independent assessment of clinical evidence
- Paediatrician consultant did not escalate care despite abnormal haematological and electrolyte results
- Tele-triage nurse lacked training in assessing non-verbal developmentally delayed children
- Duodenal ulcers are rare in children, increasing diagnostic difficulty
Coroner's recommendations
- That consideration be given to providing an in service session to all tele triage nurses, based on the Coroner's findings and suitably anonymised
- That consideration be given to implementing the Health Contact Centre's 'Global Developmental Delay Training Package' and 'Education on identification of developmental delay in children' education program to all current and new 13 Health tele triage nurses
- That consideration be given to creating a 13 Health policy that ensures that tele triage nurses consult about their advice with the Nurse Unit Manager where the caller has conveyed to the tele triage nurse that the patient is a child with developmental delay
Full text
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