Simpsonkaneesha3718 09

5y · Female·Cardiac and respiratory arrest probably connected with embolic stroke

A 5-year-old Aboriginal child with complex congenital heart disease (DORV with asplenia and situs inversus) died of cardiac arrest from embolic stroke. She had undergone initial BT shunt surgery but required a Glenn shunt, clearly indicated after cardiac catheterization in 2006-2007. Critical failures in care coordination led to her death: loss to follow-up for extended periods due to poor communication between cardiologist and surgeon; no written surgical plans or formal referrals; no backup appointment system; failure to monitor and escalate clinical deterioration (low oxygen saturation, functional decline reported by Karitane); no formal surgical waiting list. She waited at least 8 months for surgery after angiography in April 2009, then died in December 2009 before the operation. The coroner recommended formalizing surgical prioritization, implementing documented care plans with written inter-specialist communication, establishing backup appointments, and maintaining surgical waiting lists.