Coroner's Finding: QUINN Latoya Shelley

Contributing factors

• inadequate neurological examination due to patient non-cooperation
• failure to refer to tertiary centre for imaging despite shunt history and severe headache
• flawed telephone consultation with paediatric registrar instead of neurosurgeon
• communication breakdown: discrepancies between what was said in telephone consultation
• failure to adequately warn mother about danger signs, particularly vomiting
• premature discharge at 11pm on a Saturday without appropriate monitoring
• understaffing with three inexperienced medical officers covering 33 patients
• junior doctor inexperience with neurosurgical conditions
• distractive patient behaviour (agitation, disruptiveness) leading to diagnostic error
• head trauma as potential trigger for shunt blockage not adequately considered

Coroner's recommendations

1. Department of Human Services must ensure Emergency Department staff at Noarlunga Hospital have adequate training and experience at all times the department is open
2. When clinicians consult each other over the telephone, a comprehensive contemporaneous note of information imparted and consultation outcome should be placed in the clinical record
3. Clinicians consulting by telephone should be aware of communication lapses and exercise high degree of caution before reaching important conclusions on basis of telephoned information
4. When dealing with a patient with a ventriculo-peritoneal shunt complaining of headache unrelieved by mild analgesia, there should be high index of suspicion for blocked shunt and this should be excluded by expert neurological opinion and appropriate imaging before more benign diagnoses are entertained