Inquest into the Death of Masaly MOSBY
Delivered on :21 March 2017
Delivered at : Perth
Finding of : Coroner Linton
Orders/Rules : N/A
Suppression Order : N/A
Summary : The deceased was 36 days old at the time of her death, having been born on 1 September 2011 at Broome Hospital. When she was released from hospital into the care of her mother she was in good health. Over the following weeks she was seen by a child health nurse a number of times and there were no concerns for her health. Approximately one month later the deceased became unwell and was taken to the Broome Hospital by her mother. She was discharged home after being assessed by a doctor. The deceased was taken back to the Broome Hospital twice more in the following days but did not see a doctor for various reasons before she died at home.
The inquest focused primarily on the care provided to the deceased at the Broome Hospital on the three occasions she attended in early October 2011 and the reasons why the pneumonia that caused her death was not diagnosed and treated.
On the first occasion the deceased presented to the hospital she was seen by a locum doctor who had not worked in the hospital previously but had experience treating small babies. He found the deceased showed no signs of infection and ultimately diagnosed the deceased with a cold. The deceased parents were provided with Panadol and sent home but were advised to bring the deceased back to the hospital if they continued to be concerned or the deceased continued to have a fever or feeding difficulties. The Coroner concluded that on this occasion when the deceased presented at the Broome Hospital her care was reasonable given she showed no obvious signs of being unwell.
The deceased was taken to the Emergency Department by family members twice more in the following days but the deceased was not assessed by a doctor, as on both occasions the deceased was taken from the hospital before a doctor was available to see her. However, the deceased was seen by nursing staff on both occasions and she appeared to them to be reasonably well and they had no major concerns about her health that would suggest she required urgent medical attention.
The Coroner concluded that at the time the deceased was seen at Broome Hospital on 5 October 2011, if not earlier, the deceased had a respiratory infection. After returning home with her parents the infection had rapidly developed into a bacterial infection which caused her death overnight on 5 and 6 October 2011 while she was sleeping with her parents.
The Coroner heard evidence at the inquest hearing the Broome Hospital have taken steps to ensure that vulnerable babies are given appropriate and expeditious medical care if they present to the Emergency Department, and that there is less opportunity for them to be missed if they are taken from the department before a medical review. The Coroner was satisfied that these steps taken demonstrate that lessons have been learnt from the deceased’s death.
Catch Words : Bacterial Infection : Assessment of Patients at Emergency Departments : Paediatric Patients: Natural Causes.
Last updated: 30-Mar-2017
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