Finding into death of Holly Bridget Marion South

0y · Female·Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shunt

Holly South, an 8-month-old with complex congenital heart disease requiring a Blalock-Taussig shunt, died of hypoxic-ischaemic encephalopathy from thrombosis in her shunt after presenting to hospital with vomiting and signs of dehydration. Clinical lessons: the delay in medical assessment (55-58 minutes for a triage category 3 patient with critical cardiac disease) was less than acceptable. The absence of a communication system flagging her high-risk status to ED staff meant no special management plan was invoked. Nursing documentation was inadequate. The case highlights systemic communication failures between cardiology, ED, and pre-hospital services rather than individual clinical errors. Implementation of a comprehensive management card for complex cardiac conditions and alert systems could improve outcomes and reduce risk of preventable deaths in similar cases.