Inquest into the death of Sebastian Keith PARMAN

Contributing factors

• failure to diagnose and treat septic shock on 16 September 2010
• provision of maintenance fluids rather than bolus fluids despite compensated septic shock
• informal unregistered consultation with no written notes on 14 September 2010
• unclear handover between Dr Reddy and Dr Cupitt resulting in inappropriate discharge on 15 September 2010
• delay in X-ray reporting (14+ hours from imaging to radiologist review)
• failure to identify pneumonia on chest X-ray when reviewed by Dr Cupitt without clinical context
• inadequate exchange of clinical information between treating physicians
• poor documentation and note-taking throughout hospital care
• gaps in observations and vital signs monitoring in HDU
• failure of Dr Reddy to arrange urgent radiologist reporting or appropriate investigations

Coroner's recommendations

1. The Department of Health determine whether doctors in the public health system should employ the strategy of delayed prescriptions of antibiotics, and provide guidance accordingly.
2. The Western Australian Country Health Service consider and, if practicable, implement a procedure to ensure that, where appropriate, radiologists' reports of X-rays of children with potentially serious illnesses are provided to requesting clinicians with the least possible delay.