Saunders, Ryan Charles

Contributing factors

• Failure to perform septic work-up or blood cultures after lumbar puncture on admission
• Failure to obtain CRP level which would have identified bacterial infection
• Delayed diagnosis of bacterial infection until approximately 3:30pm on day 2 (too late)
• Inadequate pain management despite evidence of severe pain
• Withholding of morphine based on diagnostic concern rather than clinical need
• Incomplete assessment of child's prior analgesic therapy
• Unaware of high initial temperature (38.7°C) on arrival and prior morphine administration
• Failure to review patient after escalation of pain relief and receipt of abnormal blood results
• Consultant reliance on junior doctors without adequate oversight of deteriorating child
• Atypical presentation of Group A Streptococcal infection making clinical diagnosis difficult

Coroner's recommendations

1. Orientation of retrieval staff to include training on service capability levels of all Queensland hospitals with immediate online access
2. Review policies to ensure appropriate access to tertiary level telemedical advice for rural and regional medical officers
3. Implement forced CRP reporting tool state-wide
4. Review accessibility of educative tools and clinical guidelines on Clinical Knowledge Network
5. Develop and implement formal on-call process to ensure radiological imaging available 24/7 at Rockhampton Hospital with state-wide expansion consideration
6. Implement formal process to ensure handover between shifts at senior medical officer and consultant level at Rockhampton Hospital
7. Consider developing and implementing early warning observation system for all Queensland paediatric facilities (Children's Early Warning Tool - CEWT)
8. Implement escalation procedure for pathology reports with automated alert system for significant variances
9. Review nursing practices and processes impacting nursing care at Rockhampton Hospital
10. Undertake review of communication within healthcare team in Paediatrics Unit at Rockhampton Hospital
11. Medical Board of Queensland to consider further investigations into management and supervision by Dr Peter Roper
12. Implement recommendations from Root Cause Analysis including PLS training, rostering review, education on septic shock and toxic shock syndrome
13. Queensland Emergency Medical System Coordination Centre to review and improve sentinel event review processes and staff training
14. Forensic and Scientific Services to review mortuary practices and develop state-wide guidelines for recording, storage and retention of autopsy information
15. Ensure forensic pathologists have system access to both forensic and clinical modules in pathology system
16. Establish formalised quality improvement processes within Rockhampton Hospital Paediatric Unit including Mortality and Morbidity Committee