Coronial
WAhospital

Inquest into the Death of Little

Deceased

Sharinka Patricia Little

Demographics

0y, female

Date of death

2008-03-20

Finding date

2012-04-05

Cause of death

perinatal pneumonia in association with meconium aspiration

AI-generated summary

Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nine hours and forty minutes at Dalwallinu Hospital. Observations were taken only once, revealing elevated temperature (38°C) and heart rate (172), but no follow-up observations were conducted and no treatment was initiated. Nursing staff failed to monitor vital signs adequately despite the baby being premature and unwell. Dr Wamono, the visiting medical officer, provided no clear monitoring instructions and did not review notes on his return. The baby was transferred by volunteer ambulance without medical escort to Northam Regional Hospital, where she arrived in severe respiratory distress and died despite resuscitation attempts. The coroner found the death arose by misadventure and concluded that had observations been taken and acted upon, the baby would have had a realistic chance of survival. Key failures included inadequate vital sign monitoring, absence of clinical escalation, lack of awareness of neonatal transport services, and overseas-trained doctor with minimal induction and support.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neonatologygeneral practicemidwiferygeneral medicine

Error types

diagnosticcommunicationdelaysystem

Clinical conditions

perinatal pneumoniameconium aspirationchorioamnionitispremature birth at 35 weeks gestationlow birth weightneonatal infection

Contributing factors

  • inadequate vital sign monitoring - observations taken only once in 9 hours 40 minutes despite premature birth
  • failure to act on elevated temperature (38°C) and heart rate (172) findings
  • no regular observations after initial abnormal findings
  • lack of clear clinical instructions from medical officer to nursing staff
  • failure to recognize deteriorating condition
  • transfer without medical or nursing escort in volunteer ambulance
  • lack of awareness of Western Australian Neonatal Transport Service (WANTS/NETS)
  • inadequate induction and support for overseas-trained visiting medical officer
  • poor note-taking practices and subsequent alteration of medical records
  • no treatment initiated despite signs of infection

Coroner's recommendations

  1. Western Australian Country Health Service put in place a system whereby the taking of observations by nursing staff in appropriate cases is audited
  2. Western Australian Country Area Health Service put in place a system whereby note taking of staff is audited on a regular basis
  3. All medical staff in regional areas of Western Australia be informed about the existence and function of NETS (Newborn Emergency Transport Service, formerly WANTS)
  4. Information about the existence and function of NETS be provided to visiting medical practitioners as part of their orientation
  5. WA Department of Health review the process of induction for visiting medical officers from overseas with a view to ensuring that those practitioners are better equipped to deal with emergencies in country hospitals
  6. WA Department of Health put in place a system whereby visiting medical officers have improved access to advice and assistance from suitably qualified medical experts in a supportive environment
Full text
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