Inquest into the death of Braydon Brown

Contributing factors

• failure to escalate for medical review on 1 April when fever and persistent headache identified
• absence of physician input on 1 April presentation to nursing staff
• lack of awareness of prior presentation symptoms (29 March) by nursing staff
• miscommunication between treating doctor and duty medical officer regarding severity and clinical urgency
• duty medical officer not informed of agitation, distress, or sedation requirements
• delay in antibiotic administration (4.5 hours) due to unclear clinical authority and decision-making
• inadequate handover between on-call and resident medical staff
• locum doctor unfamiliar with escalation procedures and chain of command
• electronic records system failure resulting in loss of clinical documentation
• delayed evacuation decision and upgrade to Code 1 status

Coroner's recommendations

1. Review the roll out of tele-health facilities in the Northern Territory to ensure staff in remote clinics have access to facilities, are trained in their use, and duty medical officers and specialists are available and trained
2. Encourage changes to CARPA Standard Treatment Manual so sections on recognizing and treating meningitis are referenced to sections on headache, neck stiffness and fever
3. Make CARPA Manual more explicit about commencement of treatment for meningitis, noting the imperative to avoid delay if diagnosis is suspected
4. CARPA Manual should explicitly state at what point a Medical Officer must be notified of a condition; presence of new headache and fever alone should trigger Medical Officer referral in meningitis context
5. All clinical staff undergo regular training and up-skilling within their scope of practice, with emphasis on conditions unlikely to be encountered routinely and the need to obtain and document expert advice