Coroner's Finding: BAARTSE Leila Marijke

Contributing factors

• misreading of temperature (38°C read as 36°C) by registrar and fellow
• failure to repeat vital signs observations after initial triage
• failure to activate Level 1 Trauma Team response despite meeting criteria
• failure to obtain surgical review despite suspected abdominal trauma
• unwarranted reassurance from normal x-ray findings
• over-reliance on 'jump test' as diagnostic tool
• discharge from ED without firm diagnosis
• failure of GP to examine abdomen or take vital signs at follow-up visit
• no discharge letter provided at time of discharge
• inadequate advice to parents regarding warning signs after discharge
• no follow-up phone call to parents after discharge

Coroner's recommendations

1. Include detailed vital sign observations in discharge information documents
2. Extend follow-up phone calls from Trauma CPC to all trauma patients regardless of time of presentation
3. Fully implement all improvement strategies previously identified in quality improvement document for Leila's case
4. Fully implement additional recommendations in Appendix 1 regarding discharge summaries, discharge advice, vital signs recording, and escalation procedures
5. Review country hospital emergency teams, services, backup and staffing levels for after-hours services
6. Ensure a doctor is available on site at all hospitals designated as emergency hospitals at all times
7. Strathalbyn Hospital to obtain copies of discharge summaries for patients referred to other hospitals
8. All discharge summaries should be provided to patient/carer on discharge or via email immediately after discharge, not posted later
9. Provide written instructions to patients/carers about diagnosis, prognosis, and warning signs requiring return to ED
10. No patient should be discharged without vital signs observations taken and recorded immediately prior to discharge
11. Reviewing doctors must see all patient information including initial observations, triage observations and referral letters
12. Do not discharge children with undiagnosed abdominal injuries where specific criteria present (listed in detail in recommendation 17 of findings)
13. Clarify and amend South Australian Trauma Team Activation Criteria Level 1 definition or align with Sydney Children's Hospital criteria
14. Clarify meaning of 'laboured respirations' in trauma criteria
15. Include voluntary guarding in abdominal symptomatology in trauma criteria
16. Deliver education to all ED clinicians regarding Trauma Team Activation criteria
17. Manage suspected abdominal trauma cases using worst-case scenario approach; keep for observation if diagnosis unclear
18. Obtain surgical opinion at outset in cases of suspected internal abdominal injury where doubt exists
19. Medical practitioners seeing trauma patients discharged from tertiary hospitals should immediately contact the tertiary hospital to clarify discharge diagnosis, investigations performed, and current presentation
20. Verbal confirmation should be obtained regarding vital sign observation figures between clinician and nursing staff
21. Out-of-hours care staff should be vigilant regarding playground safety and oversee use of equipment like swings
22. Out-of-hours care staff should immediately seek medical assistance and contact parents for falls from height of 2 metres or more
23. Establish dedicated service named 'Leila's Lifeline' to enable discharged patients/carers to access rapid medical review with full cooperation from original treating hospital
24. Practitioners should initial patient files to confirm they have reviewed all information