Coronial
SAhospital

Coroner's Finding: ROBBINS Amy Louise

Deceased

Amy Louise Robbins

Demographics

16y, female

Date of death

2003-12-01

Finding date

2007-02-07

Cause of death

intra-abdominal haemorrhage due to ruptured spleen

AI-generated summary

A 16-year-old girl died from intra-abdominal haemorrhage due to ruptured spleen following a car rollover. She was transported by ambulance to the nearest hospital (Renmark) rather than the better-equipped Berri Hospital, following standard rural ambulance protocol. At Renmark, she received high-quality emergency care but lacked adequate blood supplies (only one unit of O-negative available) and surgical facilities. She was transferred to Berri after 1 hour 52 minutes for emergency surgery but died in theatre. The coroner found her survival chances would have been significantly enhanced by direct transport to Berri Hospital. Ambulance officers complied with policy and cannot be criticised. The core issue is whether rural trauma protocols require review to permit bypass of basic hospitals for time-critical cases when a better-equipped facility is accessible.

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

Specialties

trauma surgeryemergency medicineanaesthesiaparamedicine

Error types

systemdelay

Clinical conditions

ruptured spleenintra-abdominal haemorrhagehaemoperitoneumpneumothoraxhaemothoraxhypovolaemic shockbradycardic arrest

Procedures

intubationintercostal drain insertionlaparotomysplenectomy

Contributing factors

  • transport to nearest hospital (Renmark) rather than better-equipped facility (Berri)
  • inadequate O-negative blood supply at Renmark Hospital (only one unit available)
  • lack of surgical facilities at Renmark Hospital
  • lack of adequate imaging and cross-matching services at Renmark Hospital
  • delay in accessing surgery
  • time spent at Renmark Hospital for stabilisation procedures

Coroner's recommendations

  1. The Minister for Health should consider these findings and conduct a review of the systems for stocking O-negative blood in rural hospitals generally, with a view to considering whether existing stocking practices are adequate
  2. Consider reinvigorating the Major Trauma Management Working Party established by Dr Seglenieks and colleagues, which had developed protocols for trauma response in the Riverland region
  3. Consider revisiting the review of rural trauma services in light of developments in retrieval systems since the 1996 review
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.