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The clasped feet of a ten-month-old baby boy on a blue rug.

A baby just weeks old died at Royal Hobart Hospital (RHH) after staff did not follow emergency department guidelines and misdiagnosed the severity of the boy’s condition, a coroner has found.

Key points:

  • The baby boy was taken to the Royal Hobart Hospital with vomiting and fever
  • He had a life-threatening bacterial infection, which coroner Simon Cooper said doctors failed to immediately diagnose
  • He said an operation was carried out too late and the boy died from multiple organ failure days later

The boy, identified only as PY, was taken to the RHH on September 20, 2019, suffering from a fever and vomiting.

In his report, coroner Simon Cooper said PY arrived at the hospital just before midday, and was initially triaged as category 3, requiring him to be seen within 30 minutes.

“In fact, PY was not seen for 51 minutes, and then only by an ED [emergency department] intern,” Mr Cooper wrote.

It was not until around 5:30pm that an x-ray was performed, which showed the baby had a severe bowel obstruction.

Blood tests were then taken, revealing sepsis, and the decision was taken to operate “six hours after his arrival at hospital”, Mr Cooper wrote.

There was no improvement post-surgery and PY died from multiple organ failure on September 23, 2019, aged just 48 days.

Heart condition ‘obscured reality of what was happening’

In his findings, Mr Cooper said PY had been born prematurely and with a congenital heart condition.

“It seems that the knowledge of his congenital 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,” he wrote.

A building with the letters RHH at the topA building with the letters RHH at the top

Coroner Simon Cooper said the baby boy was operated on six hours after he arrived at the hospital.

However, he also noted the emergency department’s own treatment guidelines were not followed during PY’s treatment.

When PY was first observed around 1pm, he was assessed by the Children’s Early Warning Tool as a ‘7’, which requires a patient to be reviewed within 15 minutes and blood pressure taken.

“Neither of these things happened,” Mr Cooper said.

“PY’s blood pressure was not taken until 7:15pm.”

At 1:38pm a consultant found sepsis was a possible diagnosis and formulated a treatment using intravenous antibiotics, under the care of the paediatric team.

However, staff were unable to achieve IV access, and it was not until 5pm that PY was first seen by a paediatrician.

‘Delay’ in reporting the death

Mr Cooper was also critical of the handling of the aftermath of PY’s death.

“His death was not reported until his parents drew the attention of the Coronial Division to the fact of PY’s death towards the end of November of the same year,” he said.

“Because there was a delay in reporting his death, there was, necessarily, a delay in investigating.”

That delay, Mr Cooper wrote, only served to add to the pain for the family.

“Some time was taken in seeking advice from the state forensic pathologist as to whether an order should be made to exhume PY’s body to assist in that investigation,” he said.

“That would not have occurred had the fact of his death been reported earlier.”

Mr Cooper said the circumstances of PY’s death did not require him to make any further comment around the provision of health care or the prevention of further deaths.

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