Inquest into the Death of Tahlia Rose BEMBRIDGE

4y · Female·volvulus of the large intestine

Tahlia Rose Bembridge, a 4-year-old with Down syndrome and prior mid-gut volvulus, presented to Bunbury Hospital ED with vomiting and abdominal pain on 1 October 2015. Initial assessment excluded acute bowel obstruction. Despite signs of potential deterioration (progressive tachycardia, abdominal tenderness, lactic acidosis), she was managed conservatively. Transfer to PMH was arranged at 4.00 pm when coffee-ground vomiting and increased tenderness developed. During RFDS transfer, she deteriorated acutely with septic shock. Post-mortem revealed caecal volvulus with intestinal ischaemia. The coroner found care was reasonable given circumstances but identified that more frequent observations and medical reviews after 4.00 pm would have been appropriate. The case highlights challenges in recognising deterioration in non-verbal children and communication gaps regarding RFDS transfer protocols. Key learning includes the need for flexible observation protocols when transferring to higher-level care and awareness that the mode of transfer depends on early recognition of clinical urgency.