Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episodes of cardiopulmonary arrest

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vaccination and absent diarrhoea, despite several clinical red flags. Critical failures occurred overnight: nursing staff did not escalate concerns about continued vomiting, tachycardia, ketonuria, and poor fluid tolerance despite guidelines recommending consultant review. Dr G.'s diagnosis of intussusception came only after family approached him the next morning. Delays in ambulance booking, inadequate handover communication regarding the acute nature of bowel obstruction, and the paramedic crew receiving an R3 (not R1) response code contributed to deterioration during transfer. Kyran sustained multiple cardiac arrests before arriving at Sydney Children's Hospital with hypoxic ischaemic encephalopathy and ultimately died from irreversible brain injury. Key lessons: early recognition that vomiting despite nasogastric rehydration warrants escalation and imaging; clear communication of clinical urgency to nursing and retrieval services; and timely documentation of clinical decision-making.