Steer, Summer Alice

Contributing factors

• Failure of general practitioner to consider serious gastrointestinal pathology and ask about blood in stools when child presented with abdominal pain and likely melaena
• Presumptive diagnosis and treatment for Giardia without confirmatory testing
• Private hospital doctor fixating on epistaxis diagnosis despite multiple haematemeses
• Inadequate history-taking focused on bleeding disorder rather than gastrointestinal source
• Discharge of child within 15 minutes of emergency presentation with ongoing haematemesis
• Failure to weigh child on presentation to emergency department
• Poor documentation and recording practices; composite notes without timings
• Inadequate fluid balance chart recording (outputs only, not inputs; blood/vomit recorded inconsistently)
• Three presentations and two discharges from emergency department before diagnosis
• Weak phone consultation processes with external paediatric support; misrepresentation of blood loss volumes
• Failure to recognise rising heart rate trend as subtle sign of blood loss
• Hospital's inadequate post-incident investigation and delayed systems review
• Early (incorrect) diagnosis propagated through retrieval communications

Coroner's recommendations

1. Button battery manufacturers to fund development of safer batteries and cheap disposal containers; implement ACCC packaging and safety warning standards
2. Manufacturers, distributors and retailers to place adequate warnings and implement child-resistant packaging and battery compartments
3. ACCC to develop regulation mandating horizontal standards for child-resistant battery compartments and packaging standards
4. Commonwealth government to implement national battery disposal/recycling system and provide public guidance on household storage and transport
5. Queensland government to collaborate with industry to fund ongoing public awareness campaigns about battery dangers
6. All State Health Departments to develop national reporting systems, promote Poisons Information Centre services, develop protocols for battery-related injuries, and redesign 24-hour fluid balance charts
7. All paediatric hospital sites to increase awareness of button battery identification and develop algorithms for foreign body and upper gastrointestinal bleeding highlighting button batteries
8. Royal Australian and New Zealand College of Radiologists and Australian Institute of Radiographers to develop algorithms for early clinician notification of button batteries on X-ray
9. Medical colleges (ACEM, RACS, RACP) to adopt policy documents supporting prevention and identifying management strategies
10. AHPRA to raise awareness among clinicians, pharmacists and radiographers about button battery ingestion
11. Noosa Private Hospital to review hospital death review processes for impartiality and recording; implement auto-timestamped medical records; redesign fluid balance charts; implement structured phone consultation protocols with external hospitals
12. Nambour General Hospital to implement structured protocols for providing paediatric support to other hospitals, with recording of information conveyed and advice received
13. Queensland Ambulance Service to develop procedures and training to accurately record colour, consistency and volume of blood observed at scenes
14. Dr S. to make more comprehensive medical notes, record additional observations from consultations where patients suffer serious incidents or death, and consider follow-up appointments for unwell children