Kay, Brendan Scott

Contributing factors

• sub-glottic stenosis from prolonged intubation
• extreme prematurity (26 weeks 2 days gestation)
• chronic lung disease
• miscommunication between Brisbane and Townsville hospitals regarding discharge planning
• lack of overnight observation at referring hospital before home discharge
• evening/night-time car travel
• first car journey post-discharge

Coroner's recommendations

1. Active consideration should be given by clinicians in all cases as to whether neonates returning from RBWH to the referring hospital should be returned for observation at the referring hospital before discharge; however, there is no basis for a blanket policy
2. Where possible, babies with chronic lung disease born prematurely should travel in daylight after discharge home when travel exceeding 30 minutes is involved, and full feeds should be avoided; parents should be seated next to the capsule for maximum observation
3. Where a death occurs within one month of hospital discharge, the post-mortem examination report should be provided promptly to the treating hospital for provision to relevant clinicians
4. In cases of deaths in the first year of life, the forensic pathologist should consult with treating clinicians in an effort to agree on the cause of death
5. Appointment of a paediatric ENT surgeon in Townsville
6. Central Coordination should call the medical consultant or registrar on call at both hospitals in relation to transfer arrangements
7. Communication between consultants, or if not possible, between junior doctors at both hospitals about plans for back-transferred babies
8. Better communication of messages received in relation to a patient to the consultant/registrar/nurse on duty within the department
9. Training in CPR for all parents of babies with chronic lung disease
10. Simple access phone number for parents of babies with chronic conditions to enable contact with on-call neonatologist consultant or registrar
11. All babies back-transferring from Brisbane should transit in Mackay, Townsville or Cairns before returning to smaller centres
12. Post-mortem results should be communicated by a trained person, not posted to families
13. Neonatal services should provide advice to all parents regarding safety issues of transportation including infant car restraints (Australian Transportation Safety Bureau Brochure)