Marr, Hunter Campbell

Contributing factors

• parents' lack of acceptance or understanding of asthma diagnosis
• inadequate assessment of parents' understanding of asthma management
• failure to escalate or document parental denial of diagnosis as risk factor
• failure to actively assess whether parents understood danger signs and when to seek emergency care
• educational deficiencies - reliance on provision of written materials without assessment of comprehension
• missed opportunity for respiratory specialist review despite parental request
• asthma education checklist not properly completed or implemented
• incomplete handover of clinical concerns between nursing shifts
• failure to take parental concerns about cough and deterioration seriously on discharge day

Coroner's recommendations

1. Parents' lack of acceptance or understanding of the diagnosis and appropriate management of their child's potentially life-threatening illness must be flagged, documented, escalated and addressed as a matter of urgency
2. An expressed or perceived reluctance or dissatisfaction about the discharge of a child by a parent, particularly in relation to a potentially life-threatening illness, must be flagged, documented, escalated and addressed as a matter of urgency
3. Didactic education of patients and parents must be supplemented by active assessment of understanding, particularly in relation to a potentially life-threatening illness, and clinical staff must be reminded that it is what patients/parents understand that is crucial, not what information has been provided
4. Raise awareness amongst patients, parents and staff of the risk of asthma and actions for reducing the risk
5. Parents and patients must receive appropriate education aimed at reducing life-threatening episodes, with particular attention to those with prior PICU admission
6. If there are inconsistencies between parents' understanding and the working medical diagnosis, steps must be taken to address this inconsistency and these steps must be documented
7. All patients admitted to PICU for asthma are to be reviewed by the respiratory team
8. All acute asthma admissions are to be reviewed by a relevant specialist within 24 hours
9. Use particularly the admission and discharge phases as an opportunity to explore parental/patient understanding and re-educate as needed
10. Develop a strategy to escalate parental concerns (PACE model recommended)
11. Implement comprehensive discharge planning advice including all relevant points from National Asthma Council of Australia recommendations
12. Update clinical handover tools to prompt identification of parental concerns and past PICU admissions
13. Improve documentation standards with regular education to staff about importance of contemporaneous records