Inquest into the Death of Child R (Name Subject to Suppression Order)

Inquest into the Death of Child R (Name Subject to Suppression Order)

Delivered on : 29 June 2023

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : Yes

Recommendation No. 1

I recommend that the position of a nurse practitioner, also known as a nurse navigator, be filled on an ongoing basis, to undertake the care and co-ordination of children with complex needs in the East Kimberley region, and that this person be trained in cultural awareness appropriate to the region (including face-to-face training) and be trained to provide the service in accordance with trauma informed principles.

Recommendation No. 2

I recommend that the position of nurse practitioner be filled on an ongoing basis to provide practice nurse and practice manager services at the Halls Creek GP Outpatient Clinic, and that this person be trained in cultural awareness appropriate to the region (including face-to-face training) and be trained to provide the service in accordance with trauma informed principles.

Recommendation No. 3

I recommend that the GP Remote Vocational Training Scheme at the Halls Creek Hospital GP Outpatient Clinic continues to be supported and that any difficulties recruiting to the position be addressed as far as is practicable.  Also, that this person be trained in cultural awareness appropriate to the region (including face-to-face training) and be trained to provide their services in accordance with trauma -informed  principles.

Recommendation No. 4

I recommend that, in relation to SAC 1 investigations, steps are taken to ensure that a psychologist is involved, with the aim of supporting a trauma informed process.

Orders/Rules : No

Suppression Order : Yes

Suppression of the deceased child’s name from publication and any evidence likely to lead to the deceased child’s identification. 

The deceased child is to be referred to as Child R.

 

Warning: The contents of this finding may be particularly distressing to some readers. Aboriginal and Torres Strait Islander peoples are warned that this finding refers to the death of an Aboriginal child in the Kimberley region. The death was from natural causes and following treatment in a hospital.

 

Summary:  Child R died at Halls Creek Hospital on the evening of 5 January 2017 from the complications of an intestinal obstruction.  She had been at Halls Creek Hospital since 6.55 am that morning, due to abdominal pain and vomiting.  She was an Aboriginal child.  She was 11 years old.

Child R had been born with a number of congenital abnormalities, which necessitated surgical interventions after her birth and during her childhood.  One of the consequences of her condition was that she frequently experienced chronic constipation of varying severity.  Her health needs were complex, and she was on a regime of medical care and reviews with specialist paediatricians.

When she presented to Halls Creek Hospital on 5 January 2017, Child R appeared to be severely constipated.  Throughout the day, the two treating doctors developed concerns about her having a bowel obstruction.

The two treating doctors who successively examined Child R at Halls Creek Hospital both consulted with the specialist paediatrician at Broome Hospital with a view to transferring Child R to Broome Hospital.

Unfortunately, due to a number of reasons outlined in the finding, related in part to a lack of continuity of care, the specialist paediatrician’s advice, given at 8.30 am to do a phosphate enema with a call back within half an hour if it did not work, was not attended to at Halls Creek Hospital until approximately 11.30 am and it did not work. 

Meanwhile, it is now known that by approximately 10.00 am Child R was severely dehydrated and developing acute renal failure.  Unfortunately again, this was not detected by the doctors at Halls Creek Hospital in part because of the limitations of their blood testing equipment. 

The Broome specialist paediatrician accepted Child R for transfer to Broome Hospital at approximately 11.30 am.  Unfortunately again, due to a number of reasons outlined in the finding, it took approximately one more hour to contact the Royal Flying Doctor Service (RFDS).  When the RFDS was contacted at approximately 12.30 pm the severity of Child R’s condition was not able to be conveyed to them (due in part to some of the limitations at Halls Creek Hospital), and a Priority 2 rating was allocated to the evacuation. 

When the RFDS arrived at Halls Creek Hospital at approximately 5.20 pm, Child R was moribund.  A decision was made to try and transfer her to Royal Darwin Hospital (which has an ICU).  All efforts were made to stabilise Child R for transfer to Darwin, and then to resuscitate her after she went into cardiac arrest.  Child R was not able to be revived, and tragically she was pronounced dead that evening.

The State Coroner found that Child R died from the complications of an intestinal obstruction, and that her death was by way of natural causes.

The State Coroner had no criticism of the individual doctors that treated Child R, finding that the standard and quality of their medical care was adequate, within the limits of the systems and processes available to them.

However, the State Coroner found that the standard and quality of medical care provided by Halls Creek Hospital to Child R on 5 January 2017 was below the standard that should be expected of a public hospital in that area.

The State Coroner addressed submissions concerning institutional racism raised by Child R’s mother, through her lawyers the ALS.  The State Coroner made a number of comments directed towards the importance of a culturally responsive health service at Halls Creek Hospital, and recommendations directed towards improvements in resourcing at that hospital.

Catchwords: - standard of medical care – regional and remote hospitals – intestinal obstruction – natural causes – cultural awareness – resourcing – trauma informed principles

Last updated: 10-Jun-2024

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