Inquest into the Death of Collins
Deceased
Edward Thomas Collins
Demographics
0y, male
Date of death
2007-01-14
Finding date
2011-02-28
Cause of death
cardiac arrhythmia associated with surgically corrected congenital heart disease
AI-generated summary
Edward Thomas Collins was a 3-month-old neonate with surgically corrected congenital heart disease (Total Anomalous Pulmonary Venous Drainage) who died on 14 January 2007 from cardiac arrhythmia. On 13 January 2007, he presented to Mullewa Hospital with fever, tachycardia (pulse 192), and tachypnoea (respiratory rate 88), all constituting medical emergencies. The sole registered nurse, Gail Griffin, failed to contact a doctor despite alarming vital signs, instead advising parents to take the baby home with minimal monitoring instructions. The baby deteriorated overnight and died the following morning. The Coroner found that immediate medical contact, appropriate medications, and hospital transfer should have occurred on 13 January, reducing the possibility he could have been saved. The nurse's failure to escalate care was the critical clinical error, compounded by poor documentation and lack of adherence to available triage guidelines requiring doctor notification for all infants under 6 months.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to contact a doctor when vital signs indicated medical emergency
- inadequate assessment and monitoring of vital signs
- failure to escalate to higher level of care
- incomplete vital sign measurements (no blood pressure recorded)
- poor communication with receiving hospital
- lack of adherence to triage guidelines for infants under 6 months
- prematurity and low birth weight
- inadequate weight gain and weight loss
- recent major cardiac surgery with complications
Coroner's recommendations
- If Operational Circular 1485/01 is altered, guidelines should contain a clear and easy-to-understand list similar to the existing list specifying patients to be notified to a doctor by Accident and Emergency triage nursing staff
- Any updated list should continue to include all infants up to the age of 6 months and children up to the age of 5 years with pyrexia as requiring doctor notification
Full text
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Source and disclaimer
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