MILDURA Base Hospital failed to adequately take and record proper observations of a Curlwaa toddler who died soon after discharge in 2013, a coroner has found.
Nineteen-month-old Bridgett Currah was found dead in her cot the morning after her step-grandmother had taken the girl to hospital because of excessive vomiting.
In her findings handed down into Bridgett’s death yesterday, Deputy NSW coroner Teresa O’Sullivan said it was “significant and concerning” that the hospital’s failure to properly record Bridgett’s standard observations through her May 21 admission was not a one off.
Ms O’Sullivan said that while there was no suggestion of a “systemic problem” in nursing and medical staff making entries in clinical notes, there was a “fairly consistent failure” to record any of Bridgett’s proper observations on the night of her death.
The girl died from the aspiration (inhalation) of gastric contents into her airways.
The coroner yesterday recommended that nursing and medical staff at Mildura Base Hospital undergo education and training about the use of graphical observations and response charts and on the importance of taking and recording standard observations.
She further recommended that Dr Chellam Kirubakaran, who treated Bridgett on the afternoon before the night the girl died, undergo education and training about the importance of making an entry in the clinical notes for each patient review and about who has responsibility for making those entries.
A four-day inquest into the girl’s death last month was told the taking of Bridgett’s observations at the hospital were “manifestly inadequate” and the child should have been admitted for further observations.
Ms O’Sullivan said that based on the evidence given at the inquest, she considered it appropriate to make recommendations to Ramsay Health Care, the operator of Mildura Base Hospital.
Bridgett was born with an obstruction of the pulmonary artery, which required surgeries at five days old, five months and again at 13 months.
She also suffered from global developmental delay, congenital glaucoma, feeding difficulties and recurrent vomiting.
Ms O’Sullivan said that in her particular circumstances there was a “compelling” case for Bridgett to be admitted to hospital on the night she died and blood and blood gas tests should have been performed.
“While it is not suggested that one could prospectively anticipate that Bridgett would aspire vomitus, it was one risk from a range of risks she faced if she went home,” Ms O’Sullivan said.
“Because of her fragility and vulnerability and the evidence of mild dehydration, she faced real, appreciable risks of morbidity and mortality, which would have been best managed in a hospital,” she said.
The coroner found that in a telephone conversation, Dr Kirubakaran told an associate treating Bridgett that the girl was appropriate for discharge, despite step-grandmother Janet Thomas’ expectation she would be admitted to hospital.
“I do not accept that it is only in retrospect that there was a need for admission,” Ms O’Sullivan said.
“... it is evident there were deficiencies in record-keeping, the taking of observations and the performance of reviews by senior clinicians prior to discharging Bridgett Currah.”
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