Robinson, Jacinta Kate
Deceased
Jacinta Kate Robinson
Demographics
7y, female
Date of death
2002-09-26
Finding date
2005-05-04
Cause of death
cardiac tamponade due to total parenteral nutrition fluid leakage into the pericardial sac as a result of central venous line therapy
AI-generated summary
A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clinical lessons: cardiac tamponade is a rare but life-threatening complication of central lines presenting with deceptively non-specific signs (tachycardia, unobtainable blood pressure, cool peripheries, pale appearance). The patient remained alert and communicative until sudden collapse, masking severity. Critical delays occurred: pager malfunction prevented timely senior doctor notification; nursing staff did not recognise critical illness warrant emergency response team activation; no doctor considered tamponade in differential diagnosis due to rarity and lack of exposure. Earlier recognition of the triad of unobtainable BP, faint pulses, and cool peripheries—especially after 12:25 AM—might have prompted urgent imaging (echocardiogram) and cardiology consultation. Enhanced training on central line complications, awareness of decompensation patterns, and lower threshold for emergency escalation when vital signs cannot be obtained would improve outcomes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- central venous line insertion into right atrium for TPN administration
- microscopic damage to heart wall from catheter contact with myocardium
- failure to recognise signs of developing tamponade (unobtainable blood pressure, faint pulses, cool peripheries)
- pager malfunction preventing timely notification of on-call doctor
- patient remaining alert and communicative until sudden collapse, masking critical illness
- lack of clinical exposure to cardiac tamponade among treating staff
- non-specific presentation of tamponade mimicking other post-operative complications
- absence of cardiac unit at children's hospital limiting staff awareness of cardiac complications
- no echocardiogram performed despite clinical signs warranting imaging
Coroner's recommendations
- Review training in the Royal Children's Hospital for nurses and general medical staff (and intensivists) to raise awareness of possible complications of central venous line therapy including cardiac tamponade
- Enable nurses and junior medical staff to be funded to attend acute or critical care specialist training courses
- Queensland Health continue consideration of the best approach to delivery of specialist cardiac services to children in Queensland, particularly having regard to the circumstances of this death
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