Hunter- Non-inquest findings

Contributing factors

• premature closure and anchoring bias by surgical team on faecal loading and constipation diagnosis
• failure to escalate concerns to senior surgical consultant despite overnight deterioration on 15-16 March
• inadequate fluid balance chart documentation masking extent of vomiting
• poor pain assessment not accounting for autism spectrum disorder affecting pain expression
• delayed paediatric team involvement
• lack of senior clinician oversight and input after emergency department discharge
• failure to score CEWT observations on morning of 17 March delaying Code Blue activation
• lack of awareness or communication of Ryan's Rule to family
• insufficient training of surgical team in caring for children with autism
• task-focused nursing care with loss of situational awareness
• junior clinicians not considering alternative diagnoses or bilious vomiting significance

Coroner's recommendations

1. Develop a Paediatric Acute Abdominal Pain Pathway for nursing and medical staff across all facilities in the health service - adopted via Children's Health Queensland guidelines and local Paediatric acute abdominal pathway procedure with red flags and action timeframes
2. Determine requirements for and develop a shared Model of Care for paediatric inpatients - surgical consultant to review all emergency paediatric admissions within 24 hours; paediatric close observation unit established; multidisciplinary links strengthened with Queensland Children's Hospital
3. Develop and implement a process for paediatric fluid balance management and monitoring - online training package developed; mandatory training for all paediatric ward staff with documented compliance
4. Develop and implement model specific to the paediatric unit to address professional accountability and clinical escalation responsibilities with supportive leadership - Paediatric RN Clinical Performance Assessment Tool implemented; General Surgery professional practice framework developed; incoming junior doctors receive orientation on escalation processes and recognition of deteriorating patients
5. Commit to implementation of the Statewide Paediatric Sepsis Pathway - HHS member of collaborative since late 2020; pathways implemented across facilities including regional hospital
6. Develop and implement a Paediatric Nursing admission tool for children with developmental disorders - Special considerations for autism, intellectual disability and like conditions tool developed to guide pain assessment and family-informed strategies