Hunter- Non-inquest findings
Deceased
Hunter
Demographics
8y, male
Date of death
2020-03-17
Finding date
2023-02-13
Cause of death
ischaemic bowel due to strangulated small bowel obstruction secondary to congenital band adhesion
AI-generated summary
An eight-year-old boy with autism spectrum disorder (level 1) died from ischaemic bowel due to strangulated small bowel obstruction from a rare congenital band adhesion. He presented to a regional hospital with abdominal pain and vomiting after ingesting cotton material. Despite initial appropriate assessment, clinical deterioration was not recognised or escalated. Key failures included: premature closure and anchoring bias on constipation/faecal loading; inadequate fluid balance documentation masking vomiting severity; failure to seek senior surgical review despite overnight clinical deterioration and parental concerns; delayed paediatric involvement; poor pain assessment not accounting for autism; missed opportunity to score observations using CEWT leading to delayed Code Blue activation. Senior clinician oversight was absent. The coroner found adequate initial assessment but significant failures in recognising evolving pathology and responding to deterioration, compounded by not listening to parental advocacy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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
- 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
- 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
- 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
- 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
- Commit to implementation of the Statewide Paediatric Sepsis Pathway - HHS member of collaborative since late 2020; pathways implemented across facilities including regional hospital
- 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
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