Inquest into the Death of Scafidas, Allegra Amelie

Contributing factors

• Failure to recognise constellation of symptoms suggestive of serious infection during telephone triage
• Nurse selected paediatric vomiting guideline rather than fever guideline despite fever meeting diagnostic criteria
• Inadequate assessment of critical symptoms: shallow rapid breathing, whimpering, altered sleep patterns, drowsiness
• Question 11911 threshold ('very sick') too high; insufficient prompting for assessment of alertness, activity level changes, and breathing abnormalities
• Nurse training used closed rather than open questioning, limiting elicitation of important clinical information
• Conflict between paediatric fever and vomiting guidelines resulted in wrong protocol selection
• No systematic escalation for complex or atypical presentations
• Incomplete understanding of thermometer unreliability; actual temperature may have met fever thresholds
• Inadequate recognition by nurse of symptoms concerning for pneumonia and bacterial infection
• Telephone triage limitations in assessing subtle clinical signs characteristic of early serious illness in infants

Coroner's recommendations

1. Healthdirect require registered nurses undertaking telephone triage to advise callers explicitly that the service is unable to provide a diagnosis over the telephone and that they should explain the nature of the triage service being provided.
2. Healthdirect work to improve the content of its guidelines and training given to registered nurses undertaking triage to ensure those presenting with subtle symptoms of difficult and complex cases such as pneumococcal meningitis are appropriately identified and escalated, with particular focus on recognition of symptom constellations indicating serious underlying illness.