Finding into death of Amir Mohammad Iran

Contributing factors

• Delay in recognition and escalation of abnormal blood gas results at 1:14pm on 10 August 2020 showing respiratory decompensation
• Failure to consider hyaline membrane disease as underlying diagnosis despite clinical features
• Inadequate appreciation of chest X-ray findings suggestive of RDS (reticulogranular ground glass opacities and alveolar atelectasis)
• Insufficient surfactant dosing relative to hospital guidelines and manufacturer recommendations
• Absence of repeat surfactant dosing despite ongoing respiratory deterioration
• Surfactant dosing influenced by cost considerations and vial waste rather than optimal clinical dosing
• Diagnostic fixation on bilateral pneumothoraces and PPHN limiting consideration of underlying lung pathology

Coroner's recommendations

1. That the Royal Women's Hospital, PIPER and Safer Care Victoria review their guidelines relating to surfactant to ensure prompt administration to newborns who require intubation for respiratory distress and that initial and repeat doses accord with the latest available evidence bearing in mind interstate and European guidelines and the manufacturer's user guide.
2. That parents of newborns be informed of the importance of and encouraged to notify carers in relation to any changes in colour or breathing, supported by visual signs to aid education.