Statis, Joshua Ryan

Contributing factors

• Inflammation of RVOT CardioCel patch (cause uncertain: infection, VAC dressing effect, or combination)
• Sternal wound infection
• Post-operative mediastinitis (suspected but not definitively proven)
• Suboptimal communication between cardiac surgical and PICU teams regarding extent of bleeding
• Underestimation of bleeding severity by consultant surgeon
• Delayed recognition that massive bleeding required emergency bypass
• Delay in full cardiac surgical team activation and bypass machine preparation
• VAC dressing in place over sternotomy wound
• Anticoagulation (warfarin) and ongoing antibiotic therapy

Coroner's recommendations

1. Children's Health Queensland should develop a wound inspection guideline for the cardiac surgical service to ensure consistency in documenting wound features that may be indicative of infection, including the nature and extent of wound ooze, whether it is odorous, redness or swelling, hot areas and location of affected areas, and consistency in documenting wound management plan and implementation; incorporate use of wound photographs into this guideline
2. Children's Health Queensland should continue work with its wound care team to develop better guidelines and observation mechanisms for VAC dressings, including protocols for measuring and recording VAC canister contents
3. Children's Health Queensland should formally review the cardiac surgery theatre team call-in process with a view to assessing the reasonableness and clinical merit of Surgical Fellow call-in responsibilities with reference to call-in processes operating in comparable paediatric cardiac surgical centres; consider whether call-in responsibilities should be managed by hospital switchboard or a centralised roster, similar to other urgent theatre cases and other comparable centres
4. The PICU consultant should phone the on-call cardiac surgeon whenever an ECMO call-in is made or a cardiac surgical patient in PICU becomes critically unwell to facilitate direct consultant-to-consultant discussion
5. Develop and implement revised Massive Transfusion Protocol with clear roles, responsibilities, communication channels and role cards for all team members involved
6. Implement daily updated call-in lists for on-call theatre staff prior to 3:00pm each day with reliable distribution to relevant staff
7. Implement process whereby ECMO call automatically alerts team members through hospital switchboard
8. Ensure on-call consultants are available within 30 minutes response time with nearby accommodation for those exceeding 30 minute distance
9. Implement pain assessment forms as part of routine observations on cardiac wards and develop protocols for pain measurement and recording
10. Continue investigation into whether Children's Early Warning Tool (CEWT) scoring system can be adapted for paediatric cardiac patient population to improve deterioration detection
11. Ensure cardiac surgical team members document clinical information and management specific to their specialty and scope of involvement in patient care, particularly wound management, as meaningful part of overall communication between teams in shared care model
12. Continue implementation of consultant-to-consultant communication protocols between PICU, cardiology and cardiac surgery teams
13. Review and improve liaison processes between surgical services and Infectious Diseases team across the hospital