Coroner's Finding: QUINN Latoya Shelley

12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage

A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurgical experience) examined her with difficult cooperation and consulted a paediatric registrar via telephone. The registrar advised discharge despite the shunt history and concerning symptoms including vomiting. Critical communication failures occurred: the doctor assessed neurological examination as more comprehensive than performed, misunderstood observation duration, and the mother was not warned about vomiting as an ominous sign. The girl was discharged at 11pm on a Saturday with inadequate warning signs explained. She deteriorated overnight at home and died from blocked VP shunt. Expert evidence confirmed she should have been referred for imaging and monitoring at a tertiary centre, where blocked shunt could have been diagnosed and surgically treated.