Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Children's Hospital Melbourne. After discharge to Adelaide on 1 June 2016, he was readmitted on 14 June with low oxygen saturation levels (65% acceptable minimum). Key clinical lessons: (1) Logan's oxygen saturation levels deteriorated overnight (18 readings taken, 13 below 65%) yet no further medical review occurred between 11:45pm on 14 June and 8:45am on 15 June 2016; (2) an echocardiogram should ideally have been performed at 11:45pm or earlier on 14 June rather than waiting until 8:45am on 15 June when left pulmonary artery narrowing was finally identified; (3) empirical therapies (heparin, IV fluids, oxygen) while reasonable clinical decisions not to use, would have been preferable given the unknown diagnosis and clinical uncertainty; (4) admission to PICU rather than Rose Ward would have been preferable; (5) observation charts lacked clear escalation protocols for modified saturation levels. The coroner found care decisions were reasonable in context but acknowledged earlier diagnostic investigation and care escalation would have been preferable. A rare right lung thrombus (24-48 hour duration pre-death) compounded the clinical picture.