Inquest into the Death of Gordon

Contributing factors

• failure to admit child to hospital on 25 February despite vital signs indicating serious illness
• delay in administration of parenteral antibiotics (2 hours after presentation on 26 February)
• delay in initiation of IV fluid resuscitation (4 hours after presentation)
• inadequate IV access (line tissued and not successfully reinserted)
• failure to obtain vascular access prior to RFDS transfer
• inadequate preparation for RFDS transfer
• misinterpretation of child's clinical severity
• reliance on oral fluids in critically ill child
• poor communication and coordination between treating physicians
• long delay in RFDS transfer (nearly 9 hours from initial request to arrival at appropriate facility)
• limited resources at remote hospital

Coroner's recommendations

1. Improve funding and resources for the Royal Flying Doctor Service to enable more timely transfers from remote locations
2. Improve facilities and medical resources at remote hospitals such as Halls Creek Hospital to reduce need for patient transfers
3. Ensure clear communication and coordination between medical staff, particularly regarding treatment plans and handover of care
4. Implement protocols requiring IV access to be established before RFDS transfer in critically ill children
5. Provide training to rural doctors on recognition of serious infection and sepsis in young children
6. Ensure medical records are readily accessible in emergency situations (note was made of records being unavailable)
7. Establish clear procedures for escalation of care and consultation with specialists in remote settings