Inquest into the death of Esteban FRANCO-GARCES

Contributing factors

• Delayed triage (20-minute wait)
• Delayed recognition of severity of sepsis
• Delayed involvement of senior staff in direct management
• Inadequate senior doctor oversight after initial consultant review
• Prolonged unsuccessful attempts at intravenous cannulation (approximately 30 minutes by junior registrar)
• Failure to escalate to intraosseous or intramuscular administration of antibiotics after two failed cannulation attempts
• Delayed administration of antibiotics (3-hour delay from presentation)
• Junior registrar not aware of critical blood gas results showing acidosis, elevated lactate and CO2
• Communication breakdown: failed message passing from junior registrar to senior staff
• Inadequate handover communication between clinical staff
• Lack of bedside access to electronic medical records for junior registrar
• Insufficient nursing resources in Emergency Department

Coroner's recommendations

1. Implementation of Paediatric Sepsis Pathway with laminated copies at every bed in resuscitation bay and in registration and triage sections
2. Pathway to emphasise early senior clinical involvement in patients with sepsis
3. Pathway to emphasise commencing antibiotics within 1 hour of presentation
4. Antibiotic administration should occur before fluid bolus delivery
5. Development of 'Access for Antibiotics' flow chart to guide steps and timing for IV or intramuscular antibiotic delivery
6. Implementation of Rapid Response System for all patients with immediate attendance when activated
7. Training for nursing staff on Sepsis Pathways, Handover and Rapid Response upon commencement
8. Intensive orientation for new and rotating medical staff covering Sepsis Pathways, Handover and Rapid Response
9. Full day simulation training for medical staff every 3 months
10. Introduction of bedside laptops to facilitate handover and provide bedside access to entire medical file
11. Implementation of daily 'Team Talk' for handover
12. Electronic Health Record (FirstNet) implementation to document observations, vital signs, cannulation attempts and timing
13. Mandatory bedside handover to promote effective communication and awareness of deterioration
14. Use of sepsis time clock/time bomb on dashboard to keep clinicians focused on 1-hour antibiotic requirement
15. Senior staff notification required after two failed cannulation attempts in septic patients
16. When two cannulation attempts within 10 minutes are unsuccessful: attempt intraosseous access, and if unsuccessful, administer intramuscular antibiotics immediately
17. Update Paediatric Sepsis Pathway to include reference to intramuscular administration of antibiotics
18. Increase nursing staff numbers in Emergency Department
19. Purchase of additional ultrasound machines to assist with cannulation
20. Use of 'resuscitaire' warming beds with temperature probes and heat blankets to maintain core body temperature of neonates
21. Development of quality improvement program using FirstNet data to identify children with potential sepsis and create automated alert system for clinicians