Coroner's Finding: Fergusson, Logan Scott
Deceased
Logan Scott Fergusson
Demographics
0y, male
Date of death
2016-06-15
Finding date
2023-08-30
Cause of death
hypoxia and reduced pulmonary perfusion complicating congenital heart disease
AI-generated summary
Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Children's Hospital Melbourne. After discharge to Adelaide on 1 June 2016, he was readmitted on 14 June with low oxygen saturation levels (65% acceptable minimum). Key clinical lessons: (1) Logan's oxygen saturation levels deteriorated overnight (18 readings taken, 13 below 65%) yet no further medical review occurred between 11:45pm on 14 June and 8:45am on 15 June 2016; (2) an echocardiogram should ideally have been performed at 11:45pm or earlier on 14 June rather than waiting until 8:45am on 15 June when left pulmonary artery narrowing was finally identified; (3) empirical therapies (heparin, IV fluids, oxygen) while reasonable clinical decisions not to use, would have been preferable given the unknown diagnosis and clinical uncertainty; (4) admission to PICU rather than Rose Ward would have been preferable; (5) observation charts lacked clear escalation protocols for modified saturation levels. The coroner found care decisions were reasonable in context but acknowledged earlier diagnostic investigation and care escalation would have been preferable. A rare right lung thrombus (24-48 hour duration pre-death) compounded the clinical picture.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- left pulmonary artery narrowing/restenosis post-operatively
- intravascular thrombus in right lung (24-48 hours duration)
- delayed echocardiogram investigation on 14-15 June 2016
- delayed escalation of care from Rose Ward to PICU
- lack of scheduled medical review between 11:45pm 14 June and 8:45am 15 June 2016
- observation charts lacking clear escalation protocols for modified oxygen saturation levels
- oxygen saturation levels modified to 65% minimum without clear management guidance for breaches
- empirical therapies (heparin, oxygen) not administered despite clinical uncertainty
Coroner's recommendations
- Review and improve observation charts to provide clear escalation criteria and management responses for patients with modified vital sign parameters, particularly oxygen saturation levels. (Note: The coroner acknowledged this had been addressed by the Department for Health and Wellbeing with implementation scheduled for 1 August 2022 and subsequently completed, therefore no formal recommendation made)
Full text
Related cases
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —