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Death of infant from viral meningitis (02HDC05308)

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(02HDC05308, 11 February 2004)

Rural public hospital ~ Paediatrician ~ Standard of care ~ Remote services ~ Patient transfer ~ Rights 4(1), 4(5)

A coroner questioned whether a 27-month-old boy had received care of a reasonable standard from a public hospital. The boy was admitted to a rural public hospital with possible meningitis following a high temperature, vomiting and convulsions, which occurred despite antibiotic treatment commenced the previous day.

The physician on call contacted an on-call paediatrician at another public hospital and discussed the situation with him. The boy was continued on antibiotics and fluids. The next day the boy's mother alerted staff to a blotchy red rash on his body. The house surgeon noted that the boy was sleepy and was saying things that didn't make sense. Further consultation with the paediatrician at the other hospital occurred before the boy was given a lumbar puncture, which showed viral meningitis. At the request of the paediatrician, transfer of the boy to the second public hospital was arranged.

Soon after the retrieval team arrived by air transport, the boy's condition deteriorated suddenly. An agreement was made between the paediatrician and the airflight co-ordinator to transfer the boy to a children's hospital. The boy was transferred to the Intensive Care Unit at the public hospital and mechanically ventilated awaiting arrival of the second air retrieval team. Doctors were on the telephone hourly to the paediatrician at the children's hospital. Unfortunately, the boy died before the retrieval team arrived.

It was held that the physician had not breached Right 4(1), as he sought appropriate advice from a paediatrician by telephone and managed the situation well in providing the service in a distant location. Nor did the other clinicians involved in the boy's care breach Right 4(5), as they had combined their skills and co-operated in providing appropriate care under the circumstances. The speed with which the boy's condition deteriorated, and the multiple providers involved in his care, was extremely traumatic for his mother, and there is a critical need for support and debriefing of all parties after such an incident. The Commissioner recommended that the two public hospitals review their joint policy and procedures for the management and planned transfer of paediatric patients.


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