Finding into death of Jacinta Megan Pascoe
Deceased
JACINTA MEGAN PASCOE
Demographics
<1y, female
Date of death
2007-07-10
Finding date
2010-09-03
Cause of death
Myocardial infarction
AI-generated summary
Jacinta Pascoe, a 4-week-old premature infant, died of myocardial infarction due to unclear aetiology on 10 July 2007. She presented to Austin Hospital via ambulance on 9 July with vomiting, limpness, and grunting. Clinical lessons include: paramedics should record all observations and clinical findings in patient care reports, not just interventions; triage systems must account for neonatal presentations which differ from adults; early senior neonatal input is essential for unwell infants; and adequate overnight staffing of resuscitation facilities is critical. The coroner found that although ambulance record-keeping was suboptimal and ED processes were not ideal, the underlying cardiac pathology was severe and likely present for days before symptom onset, making early clinical intervention unlikely to have changed the outcome. The hospital subsequently implemented improvements including 24-hour resuscitation room staffing and direct neonatal specialist access.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Severe myocardial damage of unclear aetiology
- Possible intimal cushion or other coronary artery abnormality
- Lesion of at least several days duration prior to presentation
- Delayed recognition of severity by paramedics
Coroner's recommendations
- Improvements to ambulance patient care reporting systems to ensure all observations and clinical findings are properly documented
- Enhanced training for paramedics in recognition of neonatal deterioration and severity assessment
- ED triage processes should account for the different presentation and assessment of neonatal patients compared to adults
- Ensure adequate overnight staffing of resuscitation facilities
- Establish direct lines of communication and access to neonatal specialist advice for ED staff
- Implementation of interosseous access devices for neonatal resuscitation
- Enhanced neonatal training and teaching for ED staff
- Direct radio communication between ambulance services and ED
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 —