Inquest into the death of Austin Facer
Deceased
Austin Facer
Demographics
6y, male
Date of death
2019-10-22
Finding date
2022-12-08
Cause of death
cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitations
AI-generated summary
Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy revealed a coronary anomaly (anomalous aortic origin of coronary artery), though the specific cause of death remained undetermined due to conflicting expert opinions. Critical clinical lessons include: (1) the systemic failures that delayed Austin's urgent transfer by over 5 hours—including suboptimal initial NETS communication, MedSTAR's unjustified shift away from the agreed Adelaide plan, and inefficient multidisciplinary coordination; (2) the importance of rapid confirmation of ventricular fibrillation and immediate escalation to transfer planning; and (3) the need for clear interstate retrieval protocols between NSW and South Australia. The coroner found the medical treatment Austin received was appropriate, but systemic communication and coordination failures created avoidable delays that may have affected his survival chances had he received timely tertiary-level assessment and investigation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- systemic deficiencies in interstate paediatric retrieval coordination
- delayed confirmation and escalation of ventricular fibrillation diagnosis
- suboptimal initial NETS consultation—lack of proactive discussion of transfer urgency
- inefficient multidisciplinary communication regarding transfer destination
- unjustified departure from agreed Adelaide transfer plan to explore Melbourne option
- failure of MedSTAR to notify NETS when transfer plan encountered uncertainty
- lack of clarity regarding clinical responsibility across state borders
- unnecessary sequential consultations instead of simultaneous multidisciplinary conference
- possible underlying coronary anomaly with unclear causal role in final collapse
- acute bronchopneumonia secondary to aspiration during initial resuscitation
Coroner's recommendations
- SCHN, NETS, MedSTAR, Women's and Children's Hospital Adelaide and Far West Local Health District to settle a mutually agreed Guideline as soon as possible covering operational and clinical processes for urgent/critically ill paediatric patient retrieval from Broken Hill Base Hospital to WCHA, including clinical consultation, logistics, bed availability and communication requirements.
- The Guideline to acknowledge NETS' responsibility to remain involved and informed in the retrieval process, including up to the point where the MedSTAR retrieval team collects the patient from Broken Hill Base Hospital.
- NETS and SCHN to continue work on developing a secure method for exchanging patients' clinical information (including relevant imaging and traces) with involved receiving clinicians, consulting clinicians, and MedSTAR, through the E-referral form and any other appropriate mechanism.
- SCHN, NETS and the Far West Local Health District to continue revising the 'Model of Care for Paediatric Patients in Far West LHD', including incorporating guidance on the responsibilities and role of NETS medical and nurse consultants and any other matters of concern.
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