Inquest into the death of Caitlin CRUZ

Contributing factors

• inaccurate and unreliable transfer of information from pre-hospital to hospital setting
• failure to convey critical vital signs (undetectable pulse, low respiratory rate, cyanosis) from medical centre to paramedics and paramedics to hospital
• delay in performance of electrocardiogram due to equipment battery failure
• failure to source alternative ECG machine
• failure to recognize abnormal ECG findings
• failure to seek senior clinician or cardiology review of abnormal ECG
• inadequate documentation of clinical observations and nursing handovers
• absence of senior medical review before transfer from ED to ward
• transfer of patient to ward without ward clerk countersigning observation chart
• incomplete neurological observations after seizure-like episode
• miscommunication between registrar and consultant regarding ECG status and patient condition
• missed opportunity to identify pericardial effusion
• inadequate blood pressure monitoring
• unavailability of medical equipment (reflex hammer, paediatric BP cuff, ECG machine)
• poor communication and handover processes

Coroner's recommendations

1. RACGP be reminded to encourage GPs to identify the destination hospital, send referral letters expeditiously, and communicate with receiving hospitals by phone when patients are transferred by ambulance from medical centres to hospitals
2. RACGP, NSW Ambulance and NSW Health explore feasibility of a consolidated electronic platform to facilitate accurate and timely transfer of clinical information and enhance patient safety during clinical handover from pre-hospital to hospital settings
3. Evidence of Nurse Unit Manager Celeste Daniels and findings be forwarded to HCCC for consideration of adequacy of explanation regarding inability to perform ECG in ED on 22 October 2016 and any further action necessary
4. Findings be provided to HCCC for further consideration of extent to which Sydney Children's Hospitals Network has demonstrated compliance with HCCC recommendations of September 2018
5. Sydney Children's Hospitals Network continue to engage with Clinical Excellence Commission to improve documentation of clinical reasoning and develop appropriate audit methods for compliance