Coroner's Finding: JOHNSON Olivia Jean

Contributing factors

• inadequate history-taking regarding frequency and volume of fluid losses
• failure to recognise or consider hypernatraemic dehydration
• reliance on skin turgor test which is unreliable in hypernatraemic dehydration
• failure to appropriately weight the mother's observations about abnormal eye appearance
• failure to account for patient's remote location (2-hour drive) when making discharge decision
• failure to establish precise details of symptom onset and severity
• inadequate assessment of dehydration risk in young infant with significant fluid losses
• premature discharge to geographically isolated location

Coroner's recommendations

1. Draw these findings and recommendations to the attention of medical practitioners throughout metropolitan and country South Australia
2. Promulgate guidelines for rural and remote medical practitioners examining infants and children with gastroenteritis, emphasising: the desirability of admission to local hospital for observation regarding possible dehydration; the need to consider hypernatraemic dehydration; careful assessment of fluid losses via vomiting and diarrhoea; consideration of difficulty in providing urgent assistance if child deteriorates in remote location; proper regard to parental observations about changes in child's appearance or behaviour; and proper detailed advice to parents on discharge
3. Encourage medical practitioners in rural and remote areas, particularly locums, to familiarise themselves with local conditions to make informed assessment of whether infants/children with gastroenteritis should be admitted or discharged
4. Advise rural and remote medical practitioners that examination of infant/child with gastroenteritis requires careful comprehensive assessment identifying illness severity and developing management plan that fully accounts for 'tyranny of distance' challenges
5. Provide point-of-care sodium level monitoring to rural and remote medical practitioners to detect hypernatraemic dehydration in gastroenteritis patients
6. Remind medical practitioners of the need to consider hypernatraemic dehydration in infants/children with gastroenteritis, noting that while infrequent it requires careful consideration and that skin turgor testing is of less significance in this condition
7. Amend the gastroenteritis protocol at Women's and Children's Hospital to reflect that infants/children with minimal dehydration discharged to geographically isolated locations should be regarded as high-risk