Urgent care 'too late' in Tas baby's death

·2-min read

A 48-day-old baby who died from sepsis at the Royal Hobart Hospital was initially wrongly assessed and staff "apparently" didn't believe his condition required urgent treatment until it was almost certainly too late.

The boy, known as PY, was rushed to the hospital's emergency department by his parents around midday on September 20, 2019 with a fever and vomiting.

He was triaged as a category three patient, requiring him to be seen within 30 minutes.

"PY was not seen for 51 minutes, and then only by an (emergency department) intern," coroner Simon Cooper wrote in findings published on Tuesday.

An assessment around 1pm ranked PY as a "seven", requiring him to be reviewed within 15 minutes and have a full children early warning assessment.

Neither of these things happened, while his blood pressure wasn't taken as required until seven hours later.

PY was born two weeks premature and had a congenital heart defect.

Mr Cooper said knowledge of the heart condition "may have served to obscure the reality of what was happening to PY, that is that he was suffering from a life-threatening bacterial infection".

Medical records indicated sepsis, an infection that causes the body's immune system to attack its own tissue, was considered at 1.38pm as a possible diagnosis.

Staff formed a treatment plan including the administration of intravenous (IV) antibiotics as soon as possible.

PY was given paracetamol while he waited to be seen by a paediatric medical officer.

He was reviewed by a paediatric registrar at 3pm but they couldn't achieve IV access. Two hours later, PY was seen by a paediatric consultant but IV access was still unsuccessful.

An X-ray at 5.34pm showed PY had a bowel obstruction, while a blood test indicated "severe sepsis".

He was transferred to intensive care following surgery, which uncovered a large bowel obstruction, but his condition continued to deteriorate.

PY developed multiple organ failure and died on September 23.

"(The) investigation leads me to conclude ... that PY's initial triaged assessment at Category 3 was wrong," Mr Cooper wrote.

"He needed to be seen much sooner than 30 minutes (even though he was not, in fact, seen for nearly an hour).

"His management thereafter was informed by medical staff apparently not believing that his condition required urgent or time-critical treatment until about 6.00pm (six hours after his arrival in hospital and by which time it was almost certainly too late to save him)."

PY's death was not initially reported to the coroner by the hospital as required by law, leading to delays in the investigation, Mr Cooper wrote.

It wasn't brought to the coroner's attention until PY's parents contacted the coronial division in late November 2019.

Mr Cooper said the solicitor general, on behalf of the secretary of Tasmania's Health Department, appeared to dispute the conclusion that PY's death was not reported but didn't explain why.

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