Coroner's Finding: HB

Contributing factors

• underestimation of asthma severity on initial assessment
• chronic asthma undertreated prior to admission with no formal diagnosis and no preventative medication
• failure to recognize deterioration over 48 hours
• misdiagnosis of severe respiratory failure as panic attack
• failure to understand that absence of wheeze indicates critical respiratory distress
• failure to transfer to ICU despite lack of response to standard therapy
• inadequate resuscitation technique with inappropriate ventilation rates post-intubation
• no documentation of bag-mask ventilation rate
• respiratory infection preceding acute exacerbation

Coroner's recommendations

1. Implementation of a protocol requiring speedy transfer to Royal Hobart Hospital Paediatric ICU in cases similar to HB's
2. Enhanced staff education on asthma pathophysiology and recognition of critical deterioration
3. Ensure salbutamol administered to children with appropriate spacer use
4. Better understanding that absence of wheeze in asthma indicates critical respiratory distress, not improvement