Coronial
VICother

Finding into death of TH

Demographics

2y, female

Coroner

State Coroner Judge Ian L Gray

Date of death

2005-05-13

Finding date

2013-08-19

Cause of death

Blunt force injury to the abdomen

AI-generated summary

A two-year-old girl died from blunt force injury to the abdomen, sustaining internal injuries including pancreatic rupture, jejunal rupture, and liver trauma with significant intra-abdominal hemorrhage. Evidence indicated the fatal injuries occurred on the evening/night of 12 May or early morning of 13 May 2005 at the boyfriend's flat. The child was taken to a medical centre around 3:30pm on 13 May already in cardiac arrest. Expert evidence established that urgent surgical intervention, if provided within hours of injury, could have saved the child's life. The coroner found the death resulted from actions and inactions of two adult caregivers present that night. Clinical lesson: severe abdominal trauma in young children presenting with lethargy, pallor, and apparent illness requires immediate emergency assessment and transfer, not expectant observation at home or in public places.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatric surgeryemergency medicinegeneral surgerypathology

Error types

delaysystem

Clinical conditions

blunt abdominal traumaintra-abdominal hemorrhageliver traumapancreatic rupturejejunal rupturebowel perforationshockcirculatory failure

Contributing factors

  • Failure to seek immediate medical attention during morning of 13 May 2005 when child was clearly unwell
  • Delay in presentation to medical care; child presented in cardiac arrest approximately 2.5 hours after becoming unwell
  • Blunt force trauma to abdomen causing rupture of pancreas and jejunum with lacerations to mesentery and liver
  • Significant intra-abdominal hemorrhage (300ml blood loss, >25% of child's blood volume)
  • Inadequate caregiver response to obvious clinical deterioration
Full text

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