Finding into death of Marcus Michael Christopher Charles

0y · Male·Complications of small bowel obstruction due to post operative adhesions

Marcus Charles, a 3-month-old neonate, died from small bowel obstruction due to postoperative adhesions following earlier surgical repair of oesophageal atresia and duodenal atresia. On 4 November 2006, paramedics attended after the mother reported vomiting but did not adequately elicit medical history, failed to recognise the significance of prior abdominal and thoracic surgery in a vomiting infant, and provided only an equivocal recommendation for hospital transfer. The mother expected transport to the Royal Children's Hospital. The coroner found the history-taking unsatisfactory, the physical examination inadequate (failing to note obvious surgical scarring the mother highlighted), and the recommendation insufficient given the clinical red flags. The coroner concluded that firm transport recommendation would have been accepted and that medical review at the hospital on 4 November would likely have resulted in successful outcome. Key failures included insufficient probing of medical history, failure to interpret vomiting in context of prior bowel and oesophageal surgery, inadequate documentation in the Patient Care Report, and insufficient assertion by paramedics given the clinical uncertainty.