Finding into death of BABY C

Contributing factors

• suboptimal initial triage assessment with incomplete vital signs
• failure to obtain heart rate, respiratory rate, and oxygen saturation at initial triage
• no reassessment of vital signs during prolonged wait in waiting room despite fever and parental risk factors
• bed blocking in Emergency Department preventing timely access to treatment cubicles
• delay in definitive treatment (1 hour 52 minutes wait)
• delay in treatment beyond recommended 60-minute timeframe for ATS category 4
• failure to perform timely re-assessment per allocated triage category
• lack of consumer awareness of 'Call for Help' escalation pathway
• inadequate staffing for concurrent adult and paediatric triage assessment

Coroner's recommendations

1. Sunshine Hospital implement a policy to ensure all patients presenting to Paediatric Emergency Department have a full triage assessment performed per ETEK standards by triage nurse, including brief history and complete vital signs (heart rate, respiratory rate, temperature, blood oxygen level, blood pressure). If initial attempt unsuccessful, staff should attempt to obtain remaining measurements while patient in waiting room within appropriate timeframe determined by Emergency Department staff.
2. Regular education, training and credentialing of triage staff with ETEK including initial assessment, vital signs recording, and paediatric considerations such as assessing distressed infants.
3. Establishment of dedicated paediatric triage area with dedicated paediatric triage staff.
4. Continue implementation of initiatives to address bed-blocking and patient flow (Director of Access and Patient Flow, centralised bed management, Daily Operating Systems senior leadership meetings).
5. Continuation of 24-hour nurse position to re-triage waiting room patients who exceed their allocated timeframe to identify clinical deterioration.
6. Increase patient and carer awareness of 'Call for Help' escalation pathway through video, posters, brochures, and triage staff communication.
7. Display of public health information on signs of deterioration in emergency department waiting room in English and other common languages.