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.
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Specialties
Error types
Clinical conditions
Procedures
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