Inquest into the Death of Rasmussen vaughn

Contributing factors

• Failure to diagnose intermittently blocked VP shunt at Fremantle Hospital on 12-14 November
• Dr P.'s lack of knowledge that VP shunts can block intermittently
• Dr P.'s misinterpretation of tense reservoir compression as non-diagnostic
• Absence of VP shunt clinical guidelines at Fremantle Hospital
• Dr M.'s failure to effectively communicate diagnosis and care plan to junior staff
• Dr M.'s failure to document diagnosis and care plan in medical notes or discharge correspondence
• Dr M.'s failure to speak directly with parents about the diagnosis
• Dr G. and Dr M.'s misunderstanding that normal reservoir compression excluded blockage
• Dr G.'s reliance on faulty reservoir compression test
• Delayed and inaccurate initial CT scan interpretation (registrar missed signs of blockage)
• Delay in specialist radiological review (Dr W. unavailable on Monday 16 November)
• Dr C.'s failure to communicate VP shunt presence to Dr K. during PICU care
• Morphine administration at Fremantle causing acute deterioration before definitive diagnosis
• Misinterpretation of CT scan by junior radiologist who gave false reassurance
• Delayed neurosurgical intervention until irreversible cerebral ischaemia occurred

Coroner's recommendations

1. Director General of Health should consider creating a single clinical guideline relating to VP shunts common to all state hospitals where paediatric patients are accepted, including advice on VP shunt failure modes (blockage, intermittent blockage, disconnection, infection), symptoms of failure (especially neck hyperextension), clinical and technical means of identifying failure, and need to refer to paediatric neurosurgeon at Princess Margaret Hospital (available on call 24/7)
2. Clinical review panel at Princess Margaret Hospital should consider publishing material for parents/carers of children with VP shunts containing information about hydrocephalus, VP shunt operation, complications, important symptoms to watch for, and where to seek help
3. Director-General of Health should consider implementing a process whereby cranial CT scans are performed and retained after VP shunt insertion or revision, stored for ready access by physicians in state hospitals accepting paediatric patients
4. Director-General of Health should consider implementing a policy ensuring hospitals dealing with paediatric patients have cranial CT scans of VP shunt patients reviewed in timely manner by expert (either employed locally or located elsewhere)
5. Director-General of Health should circulate to all physicians in state hospitals likely to treat children with VP shunts a brief summary of the clinical facts of this case with emphasis on exercising extreme caution when treating paediatric patients with VP shunts where blockage cannot be ruled out