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.
Clinical conditions
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
- 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
- Consider reinvigorating the Major Trauma Management Working Party established by Dr S. and colleagues, which had developed protocols for trauma response in the Riverland region
- Consider revisiting the review of rural trauma services in light of developments in retrieval systems since the 1996 review
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