Finding into death of BCT

2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical procedure; CAMTA1 mutation progressive cerebral palsy

BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endoscopic gastrojejunostomy (PEG-J) procedure. Critical failures included: delay in recognising bowel perforation as the cause of clinical deterioration due to cognitive bias; failure to communicate procedural difficulty from interventional radiology to the treating team; lack of documentation of specialist advice not to use the migrated tube; delayed recognition of IV access loss and hypoglycaemia; inadequate escalation to senior staff overnight despite MET calls; and ineffective communication between PICU and surgical teams. Earlier recognition of perforation and appropriate escalation could potentially have changed the outcome. The hospital implemented extensive systemic improvements including cognitive bias training, standardised procedural reporting templates, enhanced escalation procedures, expanded PICU outreach services, and revised consent processes for children under court orders.