Little Gungallida Girl
Deceased
Little Gungallida Girl
Demographics
4y, female
Coroner
Priestly
Date of death
2009-07-23
Finding date
2010-10-18
Cause of death
aspiration of vomitus and its treatment due to rheumatic carditis against a background of viral respiratory tract infection
AI-generated summary
A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21, and 22 July; nursing reviews were adequate given the clinical context of a swine flu alert. On 22 July evening, she deteriorated with tachypnoea and hypoxia, was diagnosed with upper respiratory tract infection, and treated appropriately with antibiotics, oxygen, and fluids. She improved overnight and by morning appeared stable, confirming the diagnosis. A sudden, unexpected deterioration occurred in late afternoon with vomiting and cardiac arrest. Expert evidence indicated that earlier paediatric review or transfer to Mt Isa would unlikely have changed the outcome. The coroner found no clinical need for escalation given the apparent improvement and the underlying cardiac pathology was not clinically apparent to a general practitioner. A recommendation was made for Queensland Health to develop culturally sensitive guidelines for managing deaths in Aboriginal and Torres Strait Islander communities.
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Specialties
Drugs involved
Clinical conditions
Procedures
Contributing factors
- underlying rheumatic carditis (not diagnosed clinically)
- viral respiratory tract infection
- aspiration of vomitus
- cardiac arrhythmia complicating rheumatic carditis
- complications of emergency resuscitation (incorrect endotracheal tube placement)
Coroner's recommendations
- Queensland Health develop a specific guideline for health staff dealing with cultural sensitivity issues surrounding the death of a person in an Aboriginal and Torres Strait Islander community
- Review of the use of the Primary Clinical Care Manual (PCCM) to ensure better use as a clinical standard
- Better orientation of medical officers and nursing staff prior to commencing duties including service capability, fatigue risk management, PCCM, and emergency life support skills
- Analysis of rural sole practitioner GP role to determine minimum threshold credentials required
- Medical officers serving rural and remote communities have current training appropriate to the position such as PHTLS, EMST, or PALS, with BLS/CPR as absolute minimum
- Consideration of services offered by Australian College of Rural and Remote Medicine for locum relief
- Development of clinical assessment and treatment form for children incorporating type and frequency of observations and triggers for medical officer review
- Development of district protocol and criteria for escalation of paediatric cases to District Paediatrician
- Development of district procedure mandating review of medical records for all paediatric re-presentations by a Paediatrician and mandatory handover of overnight paediatric presentations
- Review of IV fluids used on children with view to removal of 3% Glucose and 1/3 Sodium Chloride
- Review of District procedures to exclude Enrolled Nurses from assessing outpatients as primary providers and cease practice of temperature checks as sole assessment
- Development of open disclosure process adapted for use in indigenous communities to make it culturally appropriate and sensitive
Full text
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