Inquest into the Death of Miss T (Name Subject to Suppression Order)
Deceased
Miss T
Demographics
16y, female
Date of death
2016-12-25
Finding date
2021-11-29
Cause of death
acute abdominal obstruction secondary to adhesions associated with severe pelvic inflammatory disease caused by gonorrhoea
AI-generated summary
A 16-year-old Aboriginal girl died on Christmas Day 2016 from acute abdominal obstruction secondary to severe pelvic inflammatory disease caused by untreated gonorrhoea. Miss T presented to the ED twice with abdominal pain and vomiting. After her second presentation on 24 December, she was discharged home without a clear diagnosis despite abnormal blood tests (elevated white cell count, raised inflammatory markers, metabolic acidosis) suggestive of possible infection. She died at home hours later from septic shock. The coroner found the death was preventable. Key issues included: (1) failure to adequately investigate the abnormal blood results or admit for observation; (2) missed opportunity for STI diagnosis at an intervening GP visit where vaginal discharge was reported; (3) discharge of a 16-year-old without ensuring responsible adult supervision or involvement of support services; (4) pressure from the 'four-hour rule' (WEAT) contributing to premature discharge; and (5) lack of a short-stay observation unit at the hospital. The coroner emphasised heightened vigilance for sepsis in young Aboriginal people presenting with abdominal pain, and the need for improved access to sexual health testing and treatment in this high-risk population.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- untreated sexually transmitted infection (gonorrhoea)
- failure to diagnose or adequately investigate possible sepsis on second ED presentation despite abnormal blood results
- premature discharge from ED without clear diagnosis
- missed opportunity to diagnose and treat STI at intervening GP consultation where vaginal discharge was reported
- absence of short-stay observation unit at regional hospital
- pressure from four-hour rule (WEAT) on clinical decision-making
- failure to ensure responsible adult supervision at discharge for 16-year-old
- no involvement of Department of Communities prior to discharge
- dehydration, hypovolaemic shock and sepsis
- possible latent diabetes mellitus
- severe malnutrition with extremely low BMI
Coroner's recommendations
- The Honourable Roger Cook MLA, Deputy Premier and Minister for Health, should consider funding the creation of a short stay unit at Kalgoorlie Health Campus, operating under the governance of the Emergency Department similar to those at other large regional health campuses in Western Australia
- The Honourable Roger Cook MLA, Deputy Premier and Minister for Health, should consider funding the employment of Aboriginal Liaison Officers in the Kalgoorlie Health Campus Emergency Department to provide 7 days per week/24 hours per day culturally appropriate liaison service to facilitate better communication between Aboriginal patients and health staff
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