Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt and obstructive hydrocephalus

Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 November, he presented to two hospitals four times with symptoms consistent with VP shunt blockage (headache, vomiting, drowsiness, neck hyperextension, seizures). Critical clinical opportunities to diagnose the intermittently blocked shunt and arrange neurosurgical intervention were missed. At Fremantle Hospital, Dr P. found the shunt valve 'tense' but lacked knowledge that shunts block intermittently and discharged him. At Princess Margaret Hospital on 14 November, Dr M. made the correct diagnosis and ordered a CT scan, but failed to communicate this effectively to junior staff or document her findings. The message did not reach the parents, who took him home. When he collapsed at Fremantle on 15 November after morphine administration, the CT scan showed blockage but was misinterpreted by a registrar. Emergency neurosurgery at Princess Margaret Hospital on 17 November revealed complete distal catheter blockage, but irreversible cerebral ischaemia had already occurred. The coroner found the death was by misadventure and referred two doctors to AHPRA, emphasizing systematic failures in communication, documentation, clinical guidelines, and specialist radiological review.