Finding into death of NB

Contributing factors

• Failure to recognise early signs of tracheostomy obstruction (gasping, cyanosis, stiffening)
• Nurse did not assess airway patency or suction the tracheostomy tube prior to CPR
• Nurse did not perform emergency tracheostomy tube change
• Ineffective CPR without adequate ventilation through the tracheostomy
• Inappropriate positioning and back pats instead of proper emergency management
• Foster carer also failed to assess airway during resuscitation and presumed nurse had already suctioned
• Inadequate training of agency nurses in emergency tracheostomy management
• 3-hour in-house training by Colbrow did not include emergency procedures or tube changing
• Poor communication between RCH, DHHS and Colbrow regarding training standards
• RCH did not effectively communicate to DHHS the specialised nature of training required
• RCH declined to train agency nurses despite holding specialised expertise
• Nursing agency did not arrange appropriate training equivalent to RCH standards
• Lack of clear delineation of responsibility between organisations for training oversight
• Prolonged period without effective ventilation (21 minutes before paramedics suctioned and replaced tube)

Coroner's recommendations

1. To the RCH: Where RCH provides advice as to healthcare needs of a child subject to Children's Court orders, that advice should be communicated in writing to DHHS and recorded in DHHS's CRIS system and provided in writing to those providing immediate care and welfare of the child, as well as to the Children's court, parties and legal representatives, including where relevant the Court-appointed independent children's lawyer
2. To RCH, DHHS and Department of Health: Consider, develop and expand models for embedding healthcare knowledge within Child Protection, including wider roll out of the Vulnerable Children's Health Project
3. To RCH and DHHS: Review current memorandum of understanding between the two organisations to strengthen relationships and clarify ambiguities, particularly to ensure discharge planning delineates roles and responsibilities of care where a third party agency is involved, specifically clarifying whose responsibility is to ensure adequate training for staff caring for patients with tracheostomy at home and whose responsibility is to ascertain capacity of attending staff to assess and manage evolving tracheostomy emergency in home environment