Coronial
QLDhospital

James, Kesler Lee

Deceased

Kesler Lee James

Demographics

5y, male

Coroner

Priestly

Date of death

2012-02-25

Finding date

2016-06-03

Cause of death

Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic carditis with mitral valve chordal rupture

AI-generated summary

A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the severity and trajectory of his illness were underestimated. Early recognition of the critical acuity could have prompted earlier respiratory support and different retrieval arrangements. The case demonstrates how cognitive biases (diagnostic momentum, framing, confirmation bias) and failure to use Early Warning scores properly contributed to missed opportunities for escalation. Key clinical lessons include: the value of complete CEWT scoring in detecting deterioration; the critical importance of involving paediatric intensivists early in managing critically unwell children in remote settings; the need for contingency planning when retrieval is delayed; and the benefit of multidisciplinary team review during the retrieval coordination process. Had intubation been considered earlier when evidence of deteriorating gas exchange became apparent, respiratory support might have reduced cardiorespiratory workload and extended time for definitive intervention, though ultimate prognosis remained guarded due to mitral chordae rupture.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsintensive careanaesthesiaemergency medicineretrieval medicinecardiology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

furosemideampicillinceftriaxonehydrocortisoneprednisolonepenicillin

Clinical conditions

acute_rheumatic_feverrheumatic_heart_diseaseacute_heart_failurecardiogenic_shockpulmonary_oedemamitral_regurgitationmitral_valve_chordae_ruptureacute_bronchopneumoniadiffuse_alveolar_damage

Procedures

intubationmechanical_ventilationcardiopulmonary resuscitation

Contributing factors

  • Failure to complete and score CEWT charts despite abnormal observations
  • Underestimation of severity of acute heart failure and cardiogenic shock
  • Lack of early paediatric intensivist involvement in clinical decision-making
  • Delayed escalation and medical emergency team call
  • Limited local capability for intubation and mechanical ventilation of critically unwell children
  • Retrieval coordination lacking specialist paediatric expertise during coordination
  • Difficulty accessing best clinical information during remote retrieval coordination
  • Limited capability of initial retrieval team (RFDS) to transport intubated children
  • Cognitive biases affecting clinical perception: diagnostic momentum, framing, confirmation bias
  • Remote location with significant retrieval delays
  • Absence of documented differential diagnosis for unexplained deterioration
  • Lack of access to echocardiography and cardiology consultation at Mt Isa Hospital

Coroner's recommendations

  1. Each District Health Service to ensure every child admitted to hospital has clinical observations charted and CEWT scores completed, with periodic audits for compliance
  2. Review and publish CEWT guidelines for each hospital including pre-determined triggers for escalation, nature of escalation, early notification to RSQ, and paediatric intensivist consultation
  3. Incorporate education in cognitive errors and limitations into professional development programs, with CEWT as a debiasing tool
  4. Ensure CEWT charts accompany children transferring between facilities and children re-presenting with same diagnosis have observations on same chart
  5. Implement 24/7 electronic scanning and transmission of CEWT charts
  6. Ensure every critically unwell child who may require retrieval is discussed with a Paediatric Intensivist in conference with RSQ and treating doctor as soon as possible
  7. Develop consensus clinical management plans considering risk of deterioration during retrieval and contingency plans
  8. Provide additional resourcing to Townsville Hospital for Paediatric Intensivists and nurses to participate in retrieval of critically unwell children
  9. Expand Northern RSQ hub to provide 24/7 coordination of retrieval services rather than alternating with Brisbane
  10. Develop State-wide, evidence-based clinical pathway for management of children with acute cardiac conditions with stratified risk approach
  11. Initiate development of consensus model of care for clinical management of acute patients requiring retrieval involving RSQ, RFDS, Careflight, and others
  12. Include in retrieval model: early notification requirements, shared medical records platform, shared communication platform, joint team conferencing, access to specialist advice, detailed roles and responsibilities, detailed risk assessment with contingency plans and triggers
  13. Establish benchmarks for retrieval crew availability and capability and monitor performance
  14. Address logistical challenges around fatigue management and rostering of retrieval crews
  15. Establish mechanisms to ensure paediatric expertise is recruited early in coordination for children in remote retrievals
Full text
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