VIChospital

Finding into death of Callie Griffiths-I'Anson

Deceased

Callie Griffiths-I'Anson

Demographics

2y, female

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2018-01-12

Finding date

2023-03-31

Cause of death

perforated oesophagus secondary to complications of treatment of oesophageal injuries following caustic soda ingestion

AI-generated summary

Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 and was transferred to the Royal Children's Hospital (RCH). On 11 January 2018, she underwent an oesophagoscopy and dilation procedure performed to standard, but suffered an iatrogenic perforation of the oesophagus during or immediately following the procedure. The perforation went undetected despite appropriate post-operative care and discharge procedures. That evening, Callie's mother called the RCH at 10pm expressing serious concerns about Callie's deterioration, but received no return call. Callie collapsed the following morning and died. The coroner found the RCH's failure to respond to the after-hours call was wholly inadequate, though causation remains unclear. Key lessons include the need for robust after-hours protocols for post-operative concerns, enhanced triaging of after-hours calls, and consideration of vulnerable regional patients.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatric surgeryanaesthesiapaediatricsdietetics

Error types

communicationsystemdelay

Drugs involved

midazolamsevofluranefentanylpropofolatracuriumdexamethasoneparacetamoloxycodone

Clinical conditions

caustic soda ingestionoesophageal burnsoesophageal strictureoesophageal perforationperitonitissepsis

Procedures

rigid oesophagoscopyoesophageal dilationnasogastric tube insertionfluoroscopy

Contributing factors

iatrogenic oesophageal perforation during oesophagoscopy and dilation procedure on 11 January 2018
failure to detect perforation prior to discharge
inadequate response to parental telephone call at 10pm on 11 January seeking urgent medical advice
on-call surgical registrar did not return call, believing it could wait until morning
severity of initial caustic injury and weakened oesophageal tissue
remote location of family home relative to tertiary medical care

Coroner's recommendations

The Royal Children's Hospital should consider the circumstances of Callie's death and the failure of the process for accessing advice from the on-call General Surgical Registrar about a child who had undergone a recent procedure, with a view to developing a better process.
In developing a better process, the Royal Children's Hospital should consider: (a) the qualifications of the person who takes such calls in the first instance; (b) the use of technology to re-route calls; (c) early triaging or differentiation of such calls; (d) the use of structured questioning to elicit as good clinical information as possible; (e) the particular vulnerability of children living in regional or remote areas; (f) the provision of a discharge summary and/or formal handover of the child to the nearest regional hospital for follow-up.

Full text

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