Finding into death of FH C
Demographics
11y, male
Date of death
2022-06-20
Finding date
2024-09-26
Cause of death
Sepsis
AI-generated summary
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was discharged with a viral diagnosis. He re-presented on 15 June appearing critically unwell but was triaged by an incompletely trained nurse who failed to obtain vital signs. He waited 3 hours for medical review while his condition deteriorated. Critical missed opportunities occurred during triage assessment and waiting period. Earlier vital signs and thorough assessment would likely have prompted timely sepsis recognition and treatment, optimising survival chances. Contributing factors included understaffing (untrained triage nurse, insufficient nursing coverage), inadequate medical staffing overnight (single registrar), lack of appropriate waiting area due to COVID-19, and unclear escalation policies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Incomplete triage assessment by inexperienced, incompletely trained triage nurse
- Failure to obtain vital signs at triage
- Insufficient nursing staff for waiting room monitoring
- Single medical registrar overnight without consultant presence
- Wait times exceeding triage category recommendations
- Lack of appropriate paediatric waiting area (COVID-19 reconfiguration)
- Inadequate escalation policy and unclear escalation criteria
- Lack of clear parental/carer escalation process
- Delayed recognition of sepsis and critical illness
- Staffing constraints related to COVID-19 pandemic
Coroner's recommendations
- Clarify the practice around vital sign monitoring in Emergency Department for paediatric patients. If not taken at triage, vital signs should be taken within the Australian Triage Category scale time, or within 30 minutes of triage (whichever is sooner). Vital signs should continue to be taken every 30 minutes thereafter until a patient is seen by medical staff.
- Continue efforts to bolster medical staffing levels at Rosebud Hospital Emergency Department in order to ensure they are in accordance with the Australasian College for Emergency Medicine guidelines.
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