Inquest into the Death of Child R (Name Subject to Suppression Order)
Deceased
Child R
Demographics
11y, female
Date of death
2017-01-05
Finding date
2023-06-29
Cause of death
Complications of E. coli sepsis in association with intestinal obstruction due to faecal impaction of megacolon in a child with anorectal anomalies (operated)
AI-generated summary
Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 hours later from E. coli sepsis associated with intestinal obstruction due to faecal impaction of megacolon. Critical delays in management included: a three-hour delay administering the phosphate enema after consultant recommendation at 8:30am; unclear handover of care between two doctors creating a gap in responsibility; failure to transfer to Broome Hospital until 11:40am when her condition was already critical; and unavailable age-related reference ranges for blood test interpretation. The child remained in the ward rather than the Emergency Department despite being unstable. Cultural miscommunications with the Aboriginal family, inadequate staffing, and limited hospital facilities contributed to delays and diagnostic uncertainty.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Delayed administration of phosphate enema - three-hour delay after recommendation at 8:30am
- Unclear handover of care between Dr A. and Dr R. creating gap in responsibility 8:30-9:30am
- Premature diagnostic closure favouring chronic constipation over bowel obstruction
- Delayed transfer to Broome Hospital - not arranged until 11:40am
- Failure to keep unstable child in Emergency Department; admission to ward instead
- Lack of age-related reference range charts for blood test results
- Unavailable i-STAT reference ranges at 10:05am limiting recognition of severe dehydration and renal impairment
- Limited clinical facilities at Halls Creek Hospital for imaging and blood testing
- Cultural miscommunications with Aboriginal family not addressed with available Aboriginal Liaison Officer support
- Missing documentation of 4 January 2017 presentation to hospital
- Dr A.'s dual responsibilities preventing adequate monitoring - GP Outpatient Clinic and ward care
- Delay in calling Royal Flying Doctor Service - approximately one hour after decision to transfer
- Delayed recognition of bowel obstruction - focus on faecal impaction as primary diagnosis
- Child remained on ward without continuous monitoring despite instability
Coroner's recommendations
- The position of a nurse practitioner/nurse navigator should be filled on an ongoing basis to undertake care and co-ordination of children with complex needs in the East Kimberley region, trained in cultural awareness appropriate to the region including face-to-face training and trauma informed principles
- The position of practice nurse at the Halls Creek GP Outpatient Clinic should be filled on an ongoing basis with cultural awareness training appropriate to the region including face-to-face training and trauma informed principles
- The GP Remote Vocational Training Scheme at Halls Creek Hospital GP Outpatient Clinic should be continued with support for recruitment difficulties, including cultural awareness and trauma informed training
- Steps should be taken to ensure a psychologist is involved in Severity Assessment Code 1 (SAC 1) investigations to support a trauma informed process
Full text
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