Coroner's Court of Western Australia

Inquest into the Death of Miss T (Name Subject to Suppression Order)

Inquest into the Death of Miss T (Name Subject to Suppression Order)

Delivered on :29 November 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : Yes

Recommendation No.1

I recommend that the Honourable Roger Cook MLA, Deputy Premier and Minister for Health, give consideration to funding the creation of a short stay unit at Kalgoorlie Health Campus, which would operate under the governance of the emergency Department in a similar way to those already established at other large regional health campuses in Western Australia.

Recommendation No. 2

I recommend that the Honourable Roger Cook MLA, Deputy Premier and Minister for Health, give consideration to funding the employment of Aboriginal Liaison Officers in the Kalgoorlie Health Campus Emergency Department to provide a 7 days per week/24 hours per day culturally appropriate liaison service to facilitate better communication between Aboriginal patients and health staff.

Orders/Rules : N/A

Suppression Order : Yes

The deceased’s name is suppressed from publication.  The deceased should be referred to as “Miss T” in any external publication and no information should be published that might lead to the identification of the deceased.

Summary : Miss T died on 25 December 2016 from acute abdominal obstruction secondary to adhesions associated with severe pelvic inflammatory disease.  While not in the care of the Department of Communities she had regular contact with them over many years.  She was 16 years of age.

Miss T was taken by Police to the Kalgoorlie Regional Hospital on 10 December 2016 following an allegation that she had been assaulted by her father.  Miss T advised hospital staff that she had been assaulted by her father who had punched her in the abdomen.  She was given pain medication and an ultrasound was performed which showed no free fluid in her abdomen.  She was discharged from hospital but appeared to be still in considerable pain.  Miss T declined to make a statement to Police against her father and so she was taken to a relative’s home at her request.

On 15 December 2016 Miss T attended the Bega Garnbirringu Health Service for a number of complaints.  She was initially seen by an enrolled nurse and then she was reviewed by a General Practitioner.  Relevantly, Miss T mentioned a gynaecological issue as part of her list of symptoms.  A detailed assessment was undertaken with a great deal of focus on the alleged physical assault and ensuring her safety from that perspective.  Miss T declined a referral to Hope Service which is a drug and alcohol service.  She was given a script for analgesia to manage her pain and advised to present to the emergency department of the Kalgoorlie Hospital if her condition got worse. She was also asked to return the next day to explore further her gynaecological issue, but regrettably, she did not return.

On 23 December 2016, Miss T became increasingly unwell. On the morning of 24 December 2016, Miss T’s sister noticed that Miss T had vomited all around the sides of her bed during the night. An ambulance attended and Miss T was taken to the emergency department of the Kalgoorlie Regional Hospital.

Miss T was reviewed in the hospital by a doctor and blood tests were taken.  The results showed raised white blood cell count, and the treating doctor at the time discussed these results with a consultant.  It was felt that Miss T may have had an infection brewing, but it was unclear what was the source and there was no clear diagnosis. Miss T was discharged from hospital, after spending just less than four hours in hospital, and advised to see her GP for a repeat full blood count in two days. with the hope that a diagnosis would become more clear.

When Miss T arrived home she was described as appearing to be nauseous and declined anything to eat, although she was seen to drink a lot of water.  A bed was made up for her in the lounge room, with a fan on to keep her cool.  At about 4.00 am on 25 December 2016, Miss T called out to her sister that she was feeling sick.  Not long after Miss T began vomiting.  She was seen to be shaking and her eyes were rolling back in her head.  She was placed on her side and her sister tried to position Miss T's mouth open to keep her airways clear of vomit.  At this stage it was noted that Miss T’s jaw was locked shut.  An ambulance was called.  When ambulance officers arrived they found no signs of life and signs of rigor mortis. The post mortem examination identified that Miss T had an untreated sexually transmitted infection, gonorrhea, which had led to the adhesions. Other medical evidence indicated she had developed sepsis in that context, which together had led to her death.

The Court heard evidence from an expert witness that there was enough information available to her medical team at the time of her presentation to the Emergency Department to identify that Miss T required further therapy and investigation, even though she was largely asymptomatic for sepsis.  It was the expert’s opinion that had Miss T been kept in the hospital longer for further observation, it is possible her death could have been prevented. There was evidence before the Court that the absence of a diagnosis had made it difficult to admit Miss T as a patient, and a Short Stay Observation Unit attached to the Kalgoorlie Hospital ED would potentially have provided the solution to keeping Miss T in hospital for further observation.

The Deputy State Coroner made two recommendations.

Catch Words : Hospital Presentations : Domestic Violence : Communication : Timely Diagnosis and Early Identification and Treatment : Management Plan for Minor : Natural Causes

Last updated: 20-Dec-2021

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