Finding into death of Emilie Suzanne Le Coz

Contributing factors

• x-ray findings of shunt disconnection at C4-C5 not interpreted correctly by neurology team
• admission under neurology rather than neurosurgery despite suspected shunt malfunction
• failure to refer conflicting investigation results to experienced neurosurgeon prior to discharge
• misinterpretation of MRI report as chronic findings despite mention of transependymal oedema and cerebellar tonsil herniation
• overreliance on shunt function study result which was misleading due to fibrous tract bridging the gap
• inadequate communication with mother who repeatedly expressed concerns about shunt dysfunction
• junior registrars not escalating concerns to senior consultants despite conflicting findings
• absence of previous imaging for comparison during March admission
• inadequate supervision and support for junior clinical staff managing complex case

Coroner's recommendations

1. Patients presenting with history of VP shunt and suspected malfunction should be admitted under neurosurgical unit rather than neurology
2. All imaging and test results should be discussed at consultant-to-consultant level when conflicting results are available, particularly before discharge
3. Junior clinicians should be encouraged to document findings and opinions and not be hesitant about escalating concerns to seniors
4. Hospital protocols should provide easier path to consultant support for inexperienced and junior clinical staff, especially when conflicting results present
5. When investigating suspected shunt obstruction, x-ray series should be reviewed by experienced neurosurgeon before relying on shunt function study alone
6. Improved communication protocols between medical teams and long-term carers/family members should be implemented
7. Initial Investigation Checklist Guidelines for suspected blocked VP shunts should be implemented (as subsequently developed at Alfred Hospital)