Inquest into the Death of Jones Coronial

Contributing factors

• Delayed CT imaging—CT scan not performed until 13 April 2000, two days after injury
• Failure to recognise the significance of vomiting and neurological signs in a child with profound baseline neurological disability
• Lack of established neurological baseline for the patient
• Unavailability of anaesthetic services on afternoon of 12 April 2000
• Diagnostic uncertainty in assessing a child with severe congenital abnormalities
• Dr A.'s reliance on clinical judgment without neurological imaging in a complex case
• Limited serial neurological observations due to difficulty assessing the patient
• Lack of supervision and support for junior resident intern (Dr P.) in regional hospital

Coroner's recommendations

1. GPs who are consistent carers for profoundly neurologically disabled children should establish serial (annual) neurological baselines for their patients to enable assessment in cases of future trauma
2. GPs, especially those in regional areas, should consider CT scans as primary diagnostic tools for head injury where there is any difficulty establishing a satisfactory management plan
3. Where there is a delay in providing a CT scan, the doctor ordering the scan or the ongoing carer must personally reassess the patient to determine any deterioration or improvement and formulate appropriate management accordingly
4. Recognition of the need for lowered threshold for diagnostic imaging (CT scans) when clinical assessment is difficult, particularly in cases of profound disability
5. Continued support and improvement of specialist resources in regional centres, including part-time specialist coverage and supervision of junior medical staff