On 23 November 2018, the Coroner’s Court of New South Wales released its findings in the inquest into the death of Angelique Burton-Ho; a 12 year-old child who died as a result of cardio-respiratory failure shortly after being transported from Bowral Hospital to the Sydney Children’s Hospital (SCH).
Angelique presented to the Bowral Hospital Emergency Department (ED) on 9 August 2015 complaining of a sore throat and leg pain. She was admitted later that same day after deteriorating with vomiting and respiratory distress. Angelique’s past history of difficult airway and the need for special care were well documented in her medical records.
Despite concerns raised by Angelique’s mother, medical and nursing staff failed to recognise and act promptly on Angelique’s clinical decline. A decision was made on the third day of admission to transfer Angelique to SCH, however, her condition had become critical and she passed away shortly after arrival.
During inquest proceedings, Angelique’s mother gave evidence that she ‘didn’t have a voice’ and that ‘nobody was listening’ to her. Coroner Grahame was critical of the failure to properly escalate these concerns to a doctor, and opined that while there are no certainties, had Angelique been retrieved from Bowral Hospital at an earlier time, she may have had a real chance of survival.
Coroner Grahame recommended changes including the development of protocols in relation to patients who are clinically deteriorating, and that nursing staff are trained to ensure awareness and understanding of the Recognise Engage Act Call Help (REACH) Program which enables patients and their families to escalate concerns about the condition of themselves or their loved ones.
Read the findings in full here.