Coronial
VIChospital

Finding into death of Nghi Trieu Gla Pham

Deceased

Nghi Trieu Gla Pham

Demographics

4y, male

Date of death

2017-05-16

Finding date

2017

Cause of death

Complications of T-cell lymphoma

AI-generated summary

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.

Contributing factors

  • 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

  1. 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
  2. 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
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