Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nursing staff could not obtain blood pressure readings (attributed to technical difficulty). When Alyssa deteriorated with low oxygen saturation and hypoglycemia, medical staff focused on respiratory and metabolic causes rather than considering post-biopsy hemorrhage. Dr N., a registrar with no prior experience managing post-biopsy patients, reassured nursing staff despite their concerns. A cardiac arrest occurred at 2:35 PM. Emergency ultrasound showed active portal vein bleeding and massive intra-capsular hemorrhage. Emergency surgery 4 hours later could not control the bleeding. The coroner found death preventable: early recognition of hemorrhage and timely surgical intervention at 1:30 PM would likely have saved her life. Contributing factors included the absence of real-time ultrasound guidance during biopsy, failure to escalate concerns, inadequate vital sign monitoring, and undiagnosed citrin deficiency.