Finding into death of Holly Bridget Marion South
Deceased
Holly Bridget Marion South
Demographics
0y, female
Date of death
2007-02-13
Finding date
2012-09-26
Cause of death
Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shunt
AI-generated summary
Holly South, an 8-month-old with complex congenital heart disease requiring a Blalock-Taussig shunt, died of hypoxic-ischaemic encephalopathy from thrombosis in her shunt after presenting to hospital with vomiting and signs of dehydration. Clinical lessons: the delay in medical assessment (55-58 minutes for a triage category 3 patient with critical cardiac disease) was less than acceptable. The absence of a communication system flagging her high-risk status to ED staff meant no special management plan was invoked. Nursing documentation was inadequate. The case highlights systemic communication failures between cardiology, ED, and pre-hospital services rather than individual clinical errors. Implementation of a comprehensive management card for complex cardiac conditions and alert systems could improve outcomes and reduce risk of preventable deaths in similar cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- delay in medical assessment in emergency department
- inadequate nursing documentation of vital signs
- absence of alert system flagging high-risk cardiac condition
- lack of communication protocol between cardiology and ED
- dehydration
- agitation and distress during intravenous line insertion
- absence of management guidelines for complex cardiac conditions in ED
Coroner's recommendations
- RCH Department of Cardiology/Cardiac Surgery Unit and Ambulance Victoria should meet to discuss management of children with complex cardiac conditions at risk of dehydration or cyanosis, and implement a memorandum of understanding if agreed
- Consider amending 'the card' to include guidelines for Ambulance Paramedics to demonstrate collaborative approach between organisations
- Place an alert on RCH's EDIS system by Department of Cardiology/Cardiac Surgery Unit for all children with complex cardiac conditions who have been issued 'the card', as a back-up alert for families presenting without the card
- RCH should provide appropriate training to all ED staff on activation and implementation of guidelines contained in 'the card' for complex cardiac conditions
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