Inquest into the Death of BC (Subject to Suppression Order)

Contributing factors

• Undiagnosed congenital wandering spleen resulting in splenic torsion and infarction
• Functional asplenia predisposing to pneumococcal infection
• Missed critical follow-up appointment with paediatrician on 11 June 2010
• Non-receipt of PMH discharge letter by referring clinic and Department
• Failure to distribute discharge summary containing critical clinical information
• Missed four-monthly immunisations due to missed appointment
• Communication failure between PMH, WACHS facilities, and Department
• Child's location at Crocodile Hole community (remote, 230 km from Halls Creek)
• Mother's limited English comprehension of discharge instructions
• Absence of care coordination system for complex discharge planning
• Delay in recognition of clinical deterioration due to incomplete information
• Inadequate emergency response protocols for remote communities

Coroner's recommendations

1. Continued resourcing of the Aboriginal Ambulatory Care Coordination (AACC) outreach program and its expansion to all regions in Western Australia
2. Department trial a practice requiring all mothers subject to pre-birth planning processes to nominate a GP or appropriate alternative for the child for follow-up after birth
3. WACHS ensure the nominated GP receives, understands, and is supported for implementation of follow-up information and care
4. WACHS continue progress on implementation of clinical information sharing systems to facilitate sharing of patient information across the Kimberley, such as Communicare
5. Department and WACHS work together to clarify the need to provide relevant health care information to the Department for children not formally in care but with families unlikely to understand the significance of complex medical information and needing assistance with complying with medical recommendations