Finding into death of Audrey Florence Eleanor Ebbage

Contributing factors

• Failure to record blood pressure throughout admission
• Initial diagnosis of croup not reconsidered despite atypical presentation
• Lack of differential diagnosis consideration despite persistent lethargy and tachypnoea
• No chest X-ray performed when persistent tachypnoea should have prompted imaging
• No consultant paediatrician review despite admission under their nominal care
• Failure to initiate MET call despite documented physiological triggers
• Inadequate supervision of junior medical staff
• Insufficient handover and communication between junior clinicians
• No escalation to senior staff when clinical condition deteriorated
• Lethargy and other atypical features of croup not recognised as indicating alternative diagnosis

Coroner's recommendations

1. Northern Health should use this case as a training example for junior medical staff to highlight the importance of differential diagnoses, particularly when a patient's clinical condition does not improve
2. Training should emphasise conducting thorough assessments and examinations
3. Training should emphasise listening to nursing staff and parents' concerns
4. Training should emphasise escalating to senior staff appropriately
5. Training should emphasise familiarisation and understanding of hospital policies and procedures, particularly Medical Emergency Team protocols