Coroner's Court of Western Australia

Inquest into the Death of Tahlia Rose BEMBRIDGE

Inquest into the Death of Tahlia Rose BEMBRIDGE


Delivered on : 1 December 2020

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Tahlia Bembridge died on 2 October 2015 at Princess Margaret Hospital after being transferred from Bunbury Hospital. She was four years old.

Tahlia Bembridge presented at the Bunbury Hospital with a possible bowel obstruction. Investigations excluded acute obstruction, and Tahlia’s condition initially appeared to improve, but at 4.00 pm a decision was made to transfer her to PMH by the Royal Flying Doctor Service in case her condition deteriorated.

After Tahlia was transferred to the Bunbury Airport by ambulance at about 7.30 pm, her condition deteriorated abruptly. She was transferred by aircraft to Jandakot Airport where she was treated by an emergency medical team before being transferred to Princess Margaret Hospital by ambulance. Her condition deteriorated further and her heart arrested. She could not be revived. The cause of her death was volvulus (twisting) of the large intestine.

The inquest examined the treatment and care provided to Tahlia at Bunbury Hospital; particularly the failure to identify the severity of her condition and the delay in transferring her to PMH once the decision to transfer her had been made.

The Deputy State Coroner found that the care Tahlia received at Bunbury Hospital was reasonable in the circumstances.

Catch Words : Twisted Bowel : Paediatric Care : Bunbury Hospital : In-patient Transfer : Royal Flying Doctor Service : Natural Causes

Last updated: 31-Dec-2020

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