Coronial
NSWhospital

Inquest into the death of Finlay Browne

Deceased

Finlay James Browne

Demographics

16y, male

Date of death

2016-12-10

Finding date

2024-05-10

Cause of death

mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related complications

AI-generated summary

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly abnormal), faeculent vomiting, and imaging showing caecal malrotation with volvulus—his condition was not recognised as a surgical emergency until late evening. Critical delays in senior physician oversight, delayed CT imaging interpretation, and failure to escalate to surgical consultation until 9pm resulted in his surgery commencing at 11:38pm. The 7+ hour delay meant extensive bowel had become ischaemic and non-viable. Although he underwent extensive surgery and retrieved to Sydney Children's Hospital, the degree of bowel necrosis was catastrophic and contributed to his death 71 days later. Systemic failures included: no qualified emergency physician leading care, placement in an unsupervised cubicle, failure to recognise unconscious bias affecting his care, inadequate escalation pathways, and late NETS involvement. Stronger clinical leadership, earlier senior review upon learning lactate result, and proper escalation would have provided a better chance of survival.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicinesurgerypaediatricsanaesthesiapaediatric surgeryretrieval medicineintensive care

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

caecal malrotationmid-gut volvulusbowel obstructionischaemic bowelbowel necrosisperitoneal soilingseptic shockhypovolaemic shockmetabolic acidosislactic acidosisDown syndromeautism spectrum disordersleep apnoea

Procedures

CT abdomenabdominal imagingexploratory laparotomybowel devolvulationhemicolectomyintravenous cannulationintubationnasogastric tube insertionVAC dressing applicationretrieval transport

Contributing factors

  • delayed diagnosis of volvulus and bowel obstruction
  • lack of qualified emergency physician to lead care
  • failure to recognise critical lactate result (7.2 mmol/L) as indicator of life-threatening illness
  • failure to escalate to senior staff following abnormal lactate
  • delayed CT scan ordering and interpretation
  • placement of patient in unsupervised cubicle without regular observations
  • failure to take blood pressure for approximately 3 hours
  • inadequate communication between ED, surgical, and paediatric teams
  • delayed surgical consultation and referral
  • unconscious bias affecting clinical perception and care of patient with Down syndrome
  • lack of executive leadership response to major incident
  • late referral to NETS
  • staffing limitations at regional hospital
  • absence of formal escalation pathways for major clinical incidents

Coroner's recommendations

  1. WNSWLHD to consider provision of formal training to clinical staff on unconscious bias and how it influences clinical judgment, including as to persons with disabilities
  2. WNSWLHD to consider potential utility of the Australian and New Zealand College of Anaesthetists & Faculty of Pain Management Unconscious bias toolkit and prepare a similar toolkit for use by clinicians within the LHD
  3. WNSWLHD to liaise with Ministry of Health regarding review and revision of Policy Directive PD2017_001 Responding to Needs of People with Disability during Hospitalisation (January 2017) in relation to cognitive bias
  4. General Manager of Bathurst Base Hospital to formalise a clear escalation pathway for on-call executive hospital support in circumstances of a major clinical incident, including where there are two urgent competing surgical cases after hours
  5. WNSWLHD to collaborate with SCHN and NETS to ensure appropriate training for ED clinicians on Policy Directive PD2023_019 NSW Paediatric Clinical Care and Inter-hospital Transfer Arrangements
  6. WNSWLHD to collaborate with SCHN and NETS to ensure ED clinicians understand general availability of NETS for very sick babies, children and adolescents up to age 16, and for patients aged 16-18 years with chronic or complex conditions
  7. WNSWLHD to ensure ED clinicians understand benefits of early contact with NETS for very sick babies, children or adolescents
  8. SCHN to liaise with Ministry of Health regarding arrangements to ensure NETS have priority access to helicopter and fixed-wing aircraft
  9. SCHN to ensure NETS are resourced to provide sufficient teams to address child population needs, noting currently five NETS teams rotate over 24 hours compared to previously instructed six teams
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