Inquest into the death of Zena Stevens
Deceased
Zena Stevens
Demographics
2y, female
Date of death
2005-01-14
Finding date
2006-04-28
Cause of death
septicaemia
AI-generated summary
Zena Stevens, a 2.5-year-old Aboriginal girl, died from septicemia at Tennant Creek Hospital on 14 January 2005. She had presented to clinic on 11 January with fever, purulent ears and a recently lanced abscess after recent discharge from hospital without review or discharge medications. Clinic nursing staff and the District Medical Officer agreed she should be evacuated to hospital, but this decision was reversed after the District Medical Officer deferred to the Hospital Medical Superintendent's judgment based on 'normal' observations and a 'wait and see' approach. The child deteriorated over subsequent days and was eventually transported by ambulance (taking 3+ hours over dirt roads) and arrived in extremis, requiring ventilation. The senior paediatrician concluded she should have been evacuated on 11 January. Poor communication between District Medical Officer and Hospital Medical Superintendent, inadequate documentation review, and lack of clinical escalation contributed to the 2-day delay in appropriate transfer. Additionally, police failed to properly record and investigate the reportable death, allowing an inappropriate death certificate to be issued.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to evacuate child on 11 January 2005 despite clinical indication
- early discharge on 8 January 2005 without medical review and without discharge medications
- unclear decision-making between District Medical Officer and Hospital Medical Superintendent regarding evacuation
- inadequate documentation review prior to clinical decisions
- deferral of clinical judgment based on 'normal observations' without full clinical context
- absence of follow-up observations on afternoon of 11 January
- child not located by nursing staff for afternoon follow-up
- delayed ground transport (3+ hours over remote roads) instead of air evacuation
- non-compliance with antibiotics due to difficulty administering oral medications to unwell child
- incomplete transfer of clinical information between community clinic and hospital
Coroner's recommendations
- Commissioner of Police should review the position of Coroners Constable in Central Region (Alice Springs and Tennant Creek) with regard to whether responsibilities require fulltime attention or additional constable resources
Full text
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