Deceased
Tory Ganderton
Demographics
3y, male
Coroner
Decision ofDeputy State Coroner Magistrate Derek Lee
Date of death
2014-09-10
Finding date
2020-03-25
Cause of death
respiratory failure, with spinal muscular atrophy an antecedent cause
AI-generated summary
Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnutrition (50% weight loss in one month), he was transferred to Sydney Children's Hospital for nutritional assessment and multidisciplinary care. Transfer was arranged for early morning 10 September via road ambulance when beds became unavailable overnight. During transfer, Tory developed sudden respiratory deterioration requiring intubation and resuscitation, which proved unsuccessful. Key clinical issues included absence of documented end-of-life planning despite his life-limiting diagnosis, limitation of respiratory support options during transfer (humidified oxygen unavailable in NETS ambulance), severe malnutrition contributing to respiratory compromise, and inadequate parent consultation regarding transfer risks and resuscitation limits. The coroner found transfer necessary given limited nursing resources at referring hospital, but identified systemic gaps in advance care planning and end-of-life discussions for children with progressive neuromuscular disease.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
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Drugs involved
Clinical conditions
Procedures
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