Coronial Investigation

Coronial Investigation: The Tragic Death of Hunter and Its Impact on Queensland Health

In March 2020, eight-year-old Hunter tragically passed away in a regional Queensland hospital after presenting with suspected cotton ingestion. Despite his family’s concerns about his deteriorating condition, Hunter’s congenital abdominal pathology went undiagnosed until it was too late.

Diagnosed with Autism Spectrum Disorder (ASD) Level 1 at age two, Hunter’s communication difficulties complicated his diagnosis, as he could not express pain or symptoms like other children his age. His parents consistently raised concerns about his worsening condition, but these were not adequately addressed by hospital staff.

Root Cause Analysis

Following Hunter’s death, a Root Cause Analysis (RCA) was conducted, revealing several failings in the care provided. The RCA identified key areas for improvement, leading to a number of recommendations aimed at preventing similar tragedies in the future. A/Coroner Kierkegaard, in a non-inquest findings report, concluded that Hunter’s death highlighted the importance of listening to and acting upon the concerns of parents, carers, and families.

Key Recommendations from the Coronial Investigation

1. Develop a Paediatric Acute Abdominal Pain Pathway

The hospital adopted the Children’s Health Queensland guideline for managing acute abdominal pain in children. This includes a procedure for identifying “red flags” that inform the level of urgency and response required.

2. Establish a Shared Model of Care for Paediatric Inpatients

All paediatric emergency admissions must now be reviewed by a surgeon within 24 hours, and a paediatric close observation unit has been established to provide care between acute and intensive levels.

3. Implement a Paediatric Fluid Balance Management Process

An online training package for clinicians on managing and monitoring fluid balance in paediatric patients has been introduced.

4. Improve Accountability and Clinical Escalation Training

Performance assessment tools and specific training for registered nurses and junior doctors have been developed to ensure they can recognise and manage deteriorating paediatric patients effectively.

5. Commit to the Statewide Paediatric Sepsis Pathway

The hospital has rolled out both paediatric and adult sepsis pathways to ensure that early signs of sepsis are identified and treated promptly.

6. Develop a Paediatric Admission Tool for Children with Developmental Disorders

Given Hunter’s ASD, the treating team did not appreciate the communication challenges associated with his condition. A new tool has been developed to guide health professionals in assessing pain and specific health care needs for children with developmental disorders like ASD.

Ryan’s Rule: A Vital Tool for Parents and Carers

Hunter’s mother, Jodie, was not informed about Ryan’s Rule, a three-step process designed to help families escalate concerns about a patient’s condition. Ryan’s Rule was implemented after the tragic death of Ryan Saunders, a three-year-old who died due to an undiagnosed infection. The Rule ensures patients and families can request a clinical review if they believe the patient’s condition is not improving as expected.

Since Hunter’s death, the hospital has implemented better communication about Ryan’s Rule through posters, pamphlets, and staff training.

The Importance of Listening to Parents and Carers

The coroner emphasised that listening to parents and carers is crucial, particularly when caring for children with disabilities. Parents often know their child best, and their concerns should be taken seriously by healthcare professionals.If you believe medical negligence has played a role in the death of a loved one, it is vital to seek expert legal advice. Contact us to discuss your options for medical negligence claims and ensure that proper steps are taken for justice and accountability.