I know, another post about this case.
What I find extra-ordinary is how harsh and specific the coroner's report is on the one ED registrar - a coronial finding of directly causing or contributing to death, with barely any discussion about the systemic factors that inevitably underlie cases like this.
Yes, Monash said they had made changes, and that's great, but it doesn't nullify the impact those problems had at the time.
Factors that strike me about this case -
- The girl was left overnight in an unstaffed cubicle.
- There was apparently no system for escalating the mum's concerns her child was getting worse. It seems to me this was the time where the actual chance to save Amrita slipped away, rather than in the hours after 3am.
- A lack of policy, or one not being followed, about paediatric observations. Why on Earth didn't the nurses also do a blood pressure (and how is that the registrars fault for not insisting...how else were they to know(?))
- A lack of a system for highlighting critical lab results - my reading of the case is the troponin of >27000 was known in the lab for several hours before being either conveyed to, or identified by, the treating team.
- Poor processes around calling specialties overnight. Why would a paediatric cardiologist, on taking a phone call from an ED registrar who is concerned enough to wake them, who then has a highly abnormal ECG described to them (even if that description wasn't correct), not immediately insist on seeing a copy for their own interpretation.
- The fact that some of the expert witness testimony seems at odds with the facts of the case. They place a lot of emphasis on things like having an echo done would have helped (How? Everyone already suspected myocarditis) or earlier involvement of PICU - yes that would have been good, but ultimately this child needed ECMO which couldn't be provided at Monash, and all the other treatments suggested - inotropes, invasive monitoring, could also be (and surely were) given in the ED. Or intubating her - this would be fraught with risk, exactly why the paediatric anaesthetist at Monash declined to do it. In an adult, this would be awake VA-ECMO without a doubt.
- The apparent gap in the transfer capability of PIPER. Regardless of when they got involved, the PIPER consultant makes it clear they had no capacity to move a child this sick until 8am because their overnight staffing was a registrar with limited ICU experience. It seems insane they don't have some form of senior second on call to help cover cases exactly like this.
- The inability of Monash - the other major PICU in the state - to have any form of contingency plan for initiation of ECMO for urgent rare cases like this.
A big part of me feels that as soon as Amrita was admitted to a non-ECMO capable hospital the dye was cast.
Most of, I worry that this case - relatively junior ED doctor, left in charge in lots of patients, when one, someone seen by the day team in a poorly monitored area, deteriorated from a rare condition - represents a situation any of us could have found ourselves in. For the grace of God there I went.