A 19-month-old baby girl may still be alive if the Launceston General Hospital had followed its own procedures, a Tasmanian coroner has found.
The girl, referred to in Coroner Simon Cooper's report as RS, died on June 10, 2021.
He found that she died of "infarction and volvulus of the small intestine", an intestinal twist causing severe bowel obstruction and resulting in inadequate blood supply.
The coroner criticised the actions of staff at the Launceston General Hospital (LGH), especially the failure to follow actions under the Children's Early Warning Tool (CEWT) used by hospitals.
RS was taken to the LGH in the early hours of June 10, where she was triaged with a score of six under the tool, which should have resulted in the following actions:
• Notification of the team leader;
• Senior doctor review within 15 minutes;
• Complete observations a minimum of every 15 minutes;
• Notification of the inpatient team; and
• In the event of a failure to improve, immediate notification to a senior medical officer or consultant.
Two-hour wait for doctor
Coroner Cooper found RS's medical records "suggest none of this was done".
Instead, he said, the first review by a doctor was more than two hours after arriving at the hospital's emergency department.
He noted she could have been seen by a doctor earlier, but that was not reflected in the medical records.
Clinical observations were taken at 2:20am and again at 7:50am — more than five hours after they were last recorded — when they should have been taken at least every 15 minutes.
It was eventually decided she be transferred by road to the Royal Hobart Hospital (RHH).
She died soon after arriving in the paediatric intensive care unit.
'Difference between survival and death'
In his report, Coroner Cooper said he was "quite satisfied" care and treatment after her transfer to RHH "was of an entirely appropriate standard".
"However, the same cannot be said of the treatment and care RS received at the Launceston General Hospital."
The coroner found that the delays in correctly diagnosing the bowel obstruction meant RS's transfer to Hobart was also delayed.
"I consider that the evidence is plain that the failure to make that diagnosis was the result of a failure to adhere to any of the procedures mandated as a result of the score returned by the completion of the CEWT," he said.
"I consider that the failure to transfer RS to the Royal Hobart Hospital earlier may have been the difference between her survival and death."
More training, procedures changed, hospital chief says
Responding to the coroner, the hospital said it had been a "terrible tragedy".
In a statement, the Chief Executive of Hospitals North, Jen Duncan, said she acknowledged the deeply distressing nature of the case and accepted the coroner's comments.
Improvements had been made after a detailed review of the circumstances, she said.
They included "increased paediatric medical training relating to resuscitation", audits into the way observations of paediatric patients were recorded, and how paediatric patient cases were escalated.
"All recommendations are being actioned and progress is being independently monitored by the Department," she said in a statement.
Ms Duncan extended an apology to the child's family and loved ones.
The adverse coronial finding is at least the fifth against the LGH since May 2021, including one into the death of a newborn after a "traumatic" birth that was mismanaged by health staff.
Lessons learned from 'poor clinical outcomes'
Deputy Premier and former health minister Michael Ferguson said parents should continue to have confidence in the hospital.
"The good thing about our governance in Tasmania is that adverse outcomes are rigorously assessed and scrutinised, in this case, by the coroner," he said.
"When mistakes are identified, including in poor clinical outcomes, lessons are learned, and then medical specialists as well as nursing or allied health staff, or non-medical staff, are then trained in how to avoid that occurring again."
The Greens have highlighted worsening data at the LGH for the percentage of patients seen on time.
Two years ago it was 61 per cent, last week it had fallen to just over 50 per cent.
