Finding into death of BCT

Contributing factors

• failure to recognise and communicate procedural difficulty
• cognitive bias preventing consideration of bowel perforation as cause of deterioration
• lack of standardised procedural reporting template
• absence of routine post-procedure handover from interventional radiology
• failure to document specialist advice not to use migrated PEG-J tube
• continued use of migrated tube for feeds and fluids
• delayed recognition of IV access loss
• delayed recognition of hypoglycaemia
• inadequate escalation to senior medical staff overnight
• non-adherence to MET call procedures
• poorly defined referral pathways overnight
• inadequate overnight MET call model for paediatric patients
• competing and excessive workload demands on nursing and junior medical staff
• ineffective communication between PICU and surgical teams
• delay in escalation to surgical consultant
• inadequate documentation of consent process for initial procedure

Coroner's recommendations

1. Monash Health to provide a clinical space with relevant support staff for Interventional Radiology to review patients and gain informed consent before any procedures
2. Monash Health to provide Interventional Radiology a stand-alone bedcard with associated staff to facilitate all hours, in-house, and ward-based care
3. Develop and implement a learning module on Cognitive Bias for clinical staff
4. Continue progression of cognitive bias action plan with targeted training module
5. Develop standardised template for procedural reporting capturing difficulties and adverse events (implemented)
6. Implement verbal handover by radiology team to treating team when adverse events occur (implemented)
7. Require specialist teams to document both in-person and phone advice in the electronic medical record (implemented)
8. Review overnight nursing model of care for children's program
9. Review and update escalation to consultant procedures particularly overnight and in context of MET calls (implemented)
10. Clarify role of PICU clinical lead in MET calls (implemented)
11. Expand PICU Outreach to 24-hour service (implemented)
12. Ensure all MET calls are escalated to Consultant (implemented)
13. Implement automatic escalation to consultant for any delay in care (implemented)
14. Roster additional resident overnight to reduce junior doctor workload (implemented)
15. Update surgical handbook to align with paediatric escalation to consultant procedure (implemented)
16. Review and update consent to medical treatment procedure to include consents in setting of Children's Court Orders (implemented)
17. Review and implement governance process for Gastrostomy/Jejunostomies inserted by Interventional Radiology and establish database of complications (in progress, extended to early 2024)
18. Review and update Gastrostomy/Jejunostomy procedures to ensure adequate paediatric coverage (implemented)
19. Develop pre-procedure assessment and consent process
20. Develop post-procedure care and review process
21. Program to ensure learnings are shared with relevant employees (implemented)
22. Work with patient experience officer to complete open disclosure