Finding into death of ALYSSA TZE SIM CHAN

Contributing factors

• Neonatal hepatitis
• Clostridium perfringens septicaemia
• Portal vein branch penetration during liver biopsy
• Inadequate post-operative monitoring and vital sign assessment
• Failure to recognize post-operative hemorrhage as primary diagnosis
• Delay in emergency surgical intervention
• Undiagnosed citrin deficiency (underlying metabolic vulnerability)

Coroner's recommendations

1. Royal Australasian College of Physicians Paediatrics & Child Health Division and Royal Australian College of General Practitioners advise that all babies presenting with unresolved conjugated jaundice at about eight weeks, particularly those for whom liver biopsy is considered, should undergo further plasma amino acid screening to exclude citrin deficiency
2. Victorian Clinical Genetics Services establish genetic screening for babies who would otherwise undergo liver biopsies and have characteristics associated with increased likelihood of citrin deficiency
3. Victorian Clinical Genetics Services provide genetic screening for parents identified as carriers of citrin deficiency mutations
4. Royal Children's Hospital review their pre- and post-liver biopsy protocols in light of changes introduced by Southern Health in September 2006 and 2008
5. Southern Health continue to actively promote a ward culture of accessing clinical protocols when patients are booked for rarely performed procedures
6. Southern Health retain digital images of all ultrasound radiology of paediatric procedures indefinitely
7. Southern Health host a discussion between senior nursing staff in Endoscopy Suite and Ward 42N and paediatric radiologists and gastroenterologists to clarify and specify content and frequency of standard post-operative observations following paediatric liver biopsy
8. Southern Health explore the possibility of introducing permanent recording pulse oximeters in Ward 42N and the Endoscopy Suite