Nghi Pham was a 4-year-old admitted to Sunshine Hospital with facial swelling, stridor, and upper respiratory symptoms. He was examined by emergency and ENT teams, diagnosed with adenoiditis and sinusitis, and discharged after improving on antibiotics and prednisolone. He re-presented days later with severe respiratory distress, collapsed in cardiac arrest, and was found to have a large mediastinal T-cell lymphoma. He suffered profound hypoxic brain injury during prolonged resuscitation and died. The coroner found clinical management was appropriate and reasonable—the lymphoma presentation was rare and atypical, the patient clinically improved during admission, and earlier imaging would have required general anaesthetic that could have precipitated arrest given the mass size. Key learning: rare mediastinal masses can present as benign upper respiratory infection; the importance of accredited interpreters when language barriers exist; and consideration of consultant review in unusual cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Mediastinal lymphoma causing thoracic inlet obstruction not diagnosed during initial admission
Clinical improvement with prednisolone masking underlying mass effect
Rare and atypical presentation of mediastinal lymphoma
Symptoms recurred after cessation of prednisolone on discharge
Mother's limited English proficiency and use of informal family interpreter
Lack of formal consultant ENT review during inpatient admission
Coroner's recommendations
Western Health ensures that the use of an interpreter is offered at all critical points of communication, including initial admission, critical decision-making points, and discharge education
Western Health develops a best practice guideline or clear criteria to guide registrars as to which patients may require consultant review or at minimum discussion with a consultant
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 —