Neville, Elise Susannah
Deceased
Elise Susannah Neville
Demographics
10y, female
Date of death
2002-01-09
Finding date
2008-09-12
Cause of death
Head injuries due to fall from a bunk bed
AI-generated summary
Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to properly examine her, perform a Glasgow Coma Score assessment, consider significant head injury, or refer her for specialist assessment. He discharged her despite her parents' concerns. When she deteriorated dramatically and re-presented 4 hours later with fixed dilated pupils and GCS 3, there were further delays in intubation and Mannitol administration. The 2.5-hour retrieval to Royal Children's Hospital was unacceptably delayed. Brain death was confirmed and she died on 9 January 2002. Key clinical lessons: always perform thorough neurological examination in head injury, never discharge unexplained altered conscious state without investigation, maintain low threshold for admission/referral, escalate to senior staff when uncertain, and ensure safe working hours to prevent fatigue-related errors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to properly examine the patient
- Failure to perform complete Glasgow Coma Score assessment
- Failure to suspect significant head injury despite clinical indicators
- Failure to refer for specialist assessment
- Failure to admit for observation despite parents' concerns
- Culture of non-admission of children for observation at Caloundra Hospital
- Inadequate investigation with no CT scan or radiological studies
- Junior doctor fatigue from 19-hour shift
- Lack of consultation with senior colleagues
- Delays in intubation and Mannitol administration at second presentation
- Delays in medical retrieval coordination
- Helicopter pilot on-call rather than on-site
- Non-compliant bunk bed without guard rails
Coroner's recommendations
- The Neville Report be released and made public
- Queensland Health conduct a review of the capacity of rural or remote hospital facilities to perform emergency neurosurgical and vascular surgical procedures
- Proposal for funding for medical crewing of retrieval teams for aircraft be approved and implemented
- Single pilot Instrument Flight Rules helicopter be delivered to Sunshine Coast retrieval service at earliest opportunity
- Telemedicine project be brought online across the state with adequate resources
- Request for half to one FTE senior medical officer for Caloundra Hospital ED be approved
- CT scanner be installed at Caloundra Hospital by August 2009
- Medical Board of Queensland progress with priority to development of a Standard regarding regulation of excessive working hours for doctors
- Warning label on bunk beds be reviewed and revised to not be age-specific or increase age categories to at least age 14
- Working party complete deliberations on removing unsafe bunk beds from private residences and make outcome public
- OFT conduct awareness campaigns directed towards domestic market concerning bunk bed standards
- All bunk beds used in Queensland Government agency owned, managed or funded establishments comply with Australian Standard
- Regulatory Impact Statement process for extending bunk bed mandatory safety standard to commercial environment be finalised with priority
Full text
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