Coronial
WAhospital

Inquest into the Death of Tahlia Rose BEMBRIDGE

Deceased

Tahlia Rose BEMBRIDGE

Demographics

4y, female

Date of death

2015-10-02

Finding date

2020-12-01

Cause of death

volvulus of the large intestine

AI-generated summary

Tahlia Rose Bembridge, a 4-year-old with Down syndrome and prior mid-gut volvulus, presented to Bunbury Hospital ED with vomiting and abdominal pain on 1 October 2015. Initial assessment excluded acute bowel obstruction. Despite signs of potential deterioration (progressive tachycardia, abdominal tenderness, lactic acidosis), she was managed conservatively. Transfer to PMH was arranged at 4.00 pm when coffee-ground vomiting and increased tenderness developed. During RFDS transfer, she deteriorated acutely with septic shock. Post-mortem revealed caecal volvulus with intestinal ischaemia. The coroner found care was reasonable given circumstances but identified that more frequent observations and medical reviews after 4.00 pm would have been appropriate. The case highlights challenges in recognising deterioration in non-verbal children and communication gaps regarding RFDS transfer protocols. Key learning includes the need for flexible observation protocols when transferring to higher-level care and awareness that the mode of transfer depends on early recognition of clinical urgency.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

paediatricsemergency medicinesurgeryanaesthesiaintensive care

Error types

communicationdelay

Clinical conditions

volvulus of large intestinebowel obstructionseptic shockhypovolaemic shocklactic acidosisDown syndromeintestinal ischaemiaaspiration

Procedures

intravenous cannula insertionfluid resuscitationcardiopulmonary resuscitationintra-osseous accesspost-mortem examination

Contributing factors

  • failure to recognise severity of clinical deterioration
  • bowel obstruction intermittent and undiagnosed
  • inadequate observations and medical reviews after 4.00 pm decision to transfer
  • communication gaps regarding RFDS transfer protocols
  • difficulty assessing non-verbal child with Down syndrome
  • delay in transfer mode recognition and implementation
  • IV line complications during RFDS transfer
  • sudden acute re-twisting of bowel during airport transfer

Coroner's recommendations

  1. WACHS should formalise guideline for inter-hospital transfers from Bunbury Hospital and provide staff with RFDS transfer information
  2. Perth Children's Hospital should establish formal agreement to accept patients with undiagnosed abdominal pain from Bunbury Hospital
  3. Develop colour-coded observation charts and recognising/responding to clinical deterioration policies for regional hospitals
  4. Implement Parrot chart (Paediatric Acute Recognition & Response Observation Tool) for more sensitive monitoring
  5. Establish paediatric sepsis pathways with clear escalation triggers
  6. Develop clinical practice guidelines for causes of abdominal pain in children with paediatric/surgical collaboration
  7. Consider proposal for intensive care road ambulance at Jandakot Airport serving southwest region
  8. Establish inter-hospital acute patient transfer coordination function in Command Centre
  9. Ensure quarterly meetings between WACHS-SW and ambulance services to review incidents and improve transfer service
  10. Release Bunbury region from exclusive SJA ambulance contract to allow alternative ambulance providers
  11. Properly fund existing RFDS paediatric retrieval service rather than establishing new separate service
  12. Improve communication between regional and tertiary hospitals regarding transfer expectations and protocols
Full text
Official source Archived copy

Related cases

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —