Inquest into the death of Kristelle Ruby Mulladad aka Oliver

Contributing factors

• Severe obstructive sleep apnoea
• Morbid obesity
• Conservative clinical approach requiring unnecessary investigations
• Cross-cultural communication failures
• Inadequate use of interpreters or cultural liaison officers
• Delays in referral response and follow-up
• Loss of initial referral to Women's and Children's Hospital Adelaide
• Inappropriate prioritisation of referral (staged admission instead of category 1)
• Failed communication of surgery offers to family and general practitioner
• Lack of case management and coordination of care
• Staff turnover in remote clinic
• Failure to inform GP of staff changes at hospital
• Inadequate practical support for patient travel to surgery
• Misunderstanding by parents regarding surgical procedure due to language barriers

Coroner's recommendations

1. That Alice Springs Hospital adhere to the Northern Territory Hospital Network Waiting Time and Elective Treatment Services Policy and Guidelines particularly in respect of GP notification requirements
2. That Alice Springs Hospital extends the services of the Paediatric Liaison nurses to complex adolescent cases from remote communities where access to care is complicated by cross-cultural issues, remoteness, or other identified complexities
3. That the Women's and Children's Hospital Adelaide ensure the criteria for categorisation of referrals to the ENT Clinic are strictly applied