Inquest into the Death of Masaly MOSBY

Contributing factors

• failure to admit on first presentation despite tachycardia and reported fever
• incomplete reassessment on re-presentations within 72 hours
• long waiting times in Emergency Department (2 hours on final presentation)
• failure to track re-presentations to the same department
• family departing without formal medical assessment on second and third presentations
• incomplete vital sign recording at triage
• insufficient emphasis on clinical history combined with observations
• busy Emergency Department lacking adequate resources
• medical student conducting initial assessment rather than experienced doctor on third presentation
• lack of follow-up procedures for 'did not wait' patients

Coroner's recommendations

1. Continue implementation of the 'Management and Review of Do Not Wait Patients That Present to the Emergency Department Procedure' introduced November 2012, which requires Emergency Department shift coordinators to immediately review and escalate cases of patients who leave without being seen, with special consideration for paediatric patients as high-risk group
2. Maintain the Assessment and Early Management of the Unwell Child Procedure implemented May 2014, which prioritises early identification of unwell children and emphasises low threshold for admission of babies under three months, use of Traffic Light Tool for identifying serious illness, and heightened alertness when there is a second presentation within 72 hours
3. Ensure triage forms continue to prompt nurses to ask about re-presentation with similar or same symptoms within 48 hours and that medical records are retrieved immediately for every patient to enable awareness of previous presentations
4. Maintain implementation of Clinical Escalation policy and ensure all staff are trained in recognition of early signs of serious infection in neonates, including the significance of tachycardia in the context of reported fever
5. Continue paediatric rapid review clinic operating seven days per week with pathway for fast-track assessment of re-presenting children when Emergency Department DMO workload is high
6. Maintain availability of Aboriginal Liaison Officers and paediatric consultative support within Broome Hospital for children presenting to Emergency Department
7. Continue enhanced Emergency Department staffing including additional RMOs and DMOs to reduce waiting times and ensure children triaged as category 3 are seen within 30 minutes
8. Maintain physical layout improvements including increased bays and elevated 'flight deck' to enable visibility of all patients and prevent departure without being seen