Inquest into the death of Jayne Elise Duncan [2011] NSWLC 36

Local Court New South Wales

Medium Neutral Citation: Inquest into the death of Jayne Elise Duncan [2011] NSWLC 36 Hearing dates: 10/11/2010 - 11/11/2010 Decision date: 20 December 2011 Jurisdiction: Coronial Before: Magistrate van Zuylen Decision: I find that Jayne Elise Duncan died between 0815 and 0930 on 9 March 2008 at Queanbeyan of unexplained natural causes. Catchwords: CORONIAL INQUEST - death of 15 month old child - death due to unexplained natural causes - concerns as to aspects of hospital treatment - subsequent implementation of changes to medical procedures to address concerns - no recommendations made Category: Principal judgment Parties: N/A Representation: Mr Davidson (for Jayne's parents, Christopher and Robyn Duncan) Mr Fordham (for Southern NSW Local Health District) Snr Cons N Ramage (Prosecutor Assisting) File Number(s): 7/2008

JUDGMENT 1Jayne Elise Duncan was born on 7 December 2006 and was the youngest of 3 children to Christopher and Robyn Duncan. Jayne had two older brothers. On Saturday night 8 March 2008, Jayne had developed a slight chest wheeze and on Sunday 9 March 2008 she was taken to Queanbeyan District Hospital due to the described symptoms. Jayne was admitted to Hospital at 1105, observed and given medication over a period of 3 hours. Jayne was discharged at 1400 and returned home with her father. Jayne was fed and put to bed. She awoke 4 times during the night. Jayne was checked again at 0815 and seemed to be breathing a lot heavier. At about 0850 on Monday 10 March 2008, Jayne's mother again went into her room to check her. She found her not breathing and immediately transported her to Queanbeyan District Hospital, which was only a few minutes drive away from where they lived. They arrived at hospital at 0900, where the staff immediately attempted resuscitation but were unable to do so. Jayne was 15 months old. 2A decision was made to hold an Inquest for a number of reasons. The pathologist who conducted the Autopsy, Dr Janse Van Vuuren, was unable to determine a cause of death. Also, it was decided to investigate whether the treatment of Jayne in hospital was appropriate, and if criticisms were found, could recommendations be made which might improve the care and treatment of children such as Jayne when admitted to Queanbeyan District Hospital. 3Dr Janse Van Vuuren conducted the Autopsy on 11 March 2008. Dr Van Vuuren stated her opinion that the cause of death was, "undetermined natural cause". However, there was a Blood Culture Report, which detected alpha haemolytic streptococcus. During her evidence, Dr Van Vuuren agreed that bacteremia, which is the presence of bacteria in the blood, should not be present. She also said that bacteria in a deceased person can be due to decomposition or possibly a post mortem contaminant and taking all her observations made during the autopsy. She did not believe that the bacteremia was the cause of death. She agreed however, that even though, during her autopsy, she observed no evidence of bacteremia to suggest it as a cause of death, it could still be a contributing factor. 4I shall now detail the treatment that Jayne received whilst she was at Queanbeyan District Hospital on Sunday 9 March 2008. Dr Jing Jung Huang was the only emergency doctor at Queanbeyan District Hospital that day. Dr Huang had been a doctor since 2000 and had also completed a year of training in emergency medicine in 2003. Dr Huang no longer works as a doctor; she ceased practising for personal reasons in 2008. 5Jayne arrived at about 1100 and Dr Huang examined her. She had bilateral expiratory wheezes but her air entry was good and equal on both sides. Dr Huang treated her with Ventolin via the nebuliser mask. Dr Huang believed she had bronchiolitis, which is a condition that affects the lungs and can present with a wheeze. Jayne was then administered Prednisone, which is a steroid medication, and another dose of Ventolin. Dr Huang then went off to deal with other patients and returned about an hour later. She observed Jayne to be sitting up in bed, she appeared happy and she was active and interacting with her dad and drinking from a bottle. Dr Huang spoke with Jayne's father and a nurse and decided to discharge her. Jayne was discharged at 1400 with a plan for her to be reviewed within 24 hours. 6Dr Huang was cross-examined at some length at the Inquest. She agreed in hindsight that she should have kept Jayne in hospital longer for observation. She was questioned over not fully completing Jayne's Emergency Department Clinical Record and conceded that she had not done so. 7The Inquest heard evidence from Dr John Vinen and Dr David Day. Dr Vinen and Dr Day are both very highly qualified and very experienced emergency physicians. Dr Vinen was originally engaged by the solicitors for Jayne's parents and in his original report dated 5 January 2010, he stated, "I would expect an ordinary doctor to have realised that the cause of Jayne's illness was unclear and that she was not responding to treatment and therefore required investigation and admission.... What is apparent is that Dr Huang did not appreciate how unwell Jayne was at the time of her assessment and the potential for deterioration.... The deficiencies were the failure to do the basic investigation required, the failure to recognise the lack of response to treatment and as a result the need for consultation and admission. Dr Day was engaged by GILD Insurance to comment on Dr Vinen's report and consider Jayne's treatment in Queanbeyan District Hospital. In his report dated 24 September 2010, he stated, "I agree with Dr Vinen that treatment provided in the ED was appropriate. I do not agree that admission was mandated by the symptoms Jayne presented with but that a further period of observation would have been prudent before a decision on admission or discharge was made, considering the diagnosis was not clear". 8Dr Vinen and Dr Day gave expert evidence at the same time. They both confirmed their agreement on several issues. They agreed that Jayne was properly and appropriately treated whilst she was at Queanbeyan District Hospital, and they agreed that Dr Huang should have kept Jayne in hospital longer for observation. Where they clearly disagreed was Dr Vinen would have admitted Jayne to hospital whereas Dr Day stated, on the evidence present at that time, Jayne did not definitely need admission. 9Dr Huang's decision to discharge Jayne was criticised by Dr Vinen as Jayne's vital signs were increasingly abnormal, her PR (pulse rate), RR (respiration rate) and Temperature increased during her time in the ED despite the treatment administered. Dr Day accepted these concerns, but said there were a number of reassuring features; in particular that the oxygen saturations were normal throughout and the child had no features of respiratory distress at any stage during the admission. Prior to discharge the child was alert, happy, playing and drinking from her bottle. 10Dr Day was of the view that Jayne's vital signs fitted in the mild to moderate range, whilst Dr Vinen's opinion was that Jayne fitted into the moderate category. Dr Vinen was also of the view that Dr Huang should have consulted with the on call paediatric specialist with a view to admitting Jayne to hospital. He also criticised the failure to provide a Discharge letter to Jayne's father. 11In relation to the cause of death of Jayne, Dr Vinen was more inclined to advance the importance of bacteremia as the cause of death. However, Dr Vinen was not present at the autopsy conducted by the pathologist Dr Van Vuuren, and even giving due weight to his impressive qualifications, experience and Curriculum Vitae, he does not have particular expertise in pathology. Therefore, on the balance of probabilities, I am more inclined to accept the opinion of Dr Van Vuuren as to her findings on cause of death. I also am of the view, that after consideration of all the evidence on the cause of death, I am unable to say whether the wheezing that Jayne exhibited on presentation to Queanbeyan Hospital contributed to her death. 12This Inquest has not tried to attribute fault or make findings in relation to negligence or duty of care but after considering all the written evidence tendered and the oral evidence given at the Inquest, I have come to the view that there are a number of criticisms that can be made of Jayne's treatment at Queanbeyan District Hospital. 13Jayne should have been kept in Queanbeyan District Hospital for a longer period of observation than the 3 hours that occurred on 9 March 2008. Following on from this criticism of not keeping Jayne in for observation for longer, is that Dr Huang should have more carefully considered whether to get advice from a paediatric specialist with a view to admitting her to hospital. Jayne's Emergency Department Clinical Record should have been fully completed. Mr Fordham, appearing for Greater Southern Area Health Service, in his final submissions, said that deficiencies in filling out forms fully is a constant issue but its importance is part of orientation and in service training. A written Discharge Summary should have been given to Jayne's father, Mr Duncan. 14The criticisms of how Jayne was treated whilst in Queanbeyan District Hospital, how long she was kept for observation and whether she should have been admitted to hospital on 9 March 2008 have been addressed by the introduction of the, "Between the Flags" project. Dr Day provided written and oral evidence of this programme. Standard Paediatric Observation Charts have been introduced in hospitals throughout NSW in 2011 for various age groups (including Jayne's age group). These charts were formulated by groups of expert clinicians to allow early recognition of abnormal vital signs. Respiratory rate, oxygen saturation, heart rate, blood pressure, level of consciousness and temperature are divided into normal (white), mild (blue), moderate (yellow) and red (severe) levels. In Jayne's case, her pulse rate was initially in the yellow zone and in the red zone at 1300, but this was after Jayne had received salbutamol (Ventolin), which causes heart rate to rise. Dr Day says this was a concern. 15On behalf of the Local Health District, Mr Fordham also advised the Inquest that there are working parties in place with a view to ensuring greater communication and flow between Queanbeyan Hospital and ACT Health. Staff at Queanbeyan Hospital have been instructed about and are aware that they can communicate with specialist services at ACT Health. A Memorandum of Understanding dealing with these issues is in place. 16During the Inquest, I requested that Southern NSW Local Health District provide further information on the implementation of improved procedures. In a letter dated 9 December 2011, GILD Insurance Litigation Pty Ltd advised that the "Between the Flags" project was implemented at Queanbeyan Hospital between December 2010 and January 2011. Also, the implementation of the provision of written discharge summaries in the Queanbeyan Hospital Emergency Department occurred on 30 September 2008. 17Jayne's parents, Christopher and Robyn Duncan, were present throughout the Inquest hearing. Mr Duncan was the last person to give evidence. He had been concerned for his daughter's health and it was the first time he had taken a child to hospital with a "wheeze". He does not have any medical experience or training. As he said in his evidence, "He left it to the professionals". His wish for and participation in this Inquest concerning his daughter's death was motivated by a concern for the future welfare and happiness of all babies. Everyone at the Inquest acknowledged the tragic circumstances surrounding Jayne's death. 18From the evidence presented at this Inquest, since 2008, there have been improvements in procedures and treatment of babies taken to Queanbeyan Hospital, which appear to address the criticisms of Jayne's medical treatment. 19There has been at Queanbeyan Hospital the implementation of: - the provision of written discharge summaries to discharged patients from 30 September 2008 - the "Between the Flags" project - greater communication and flow between Queanbeyan Hospital and ACT Health 20After having considered all the evidence concerning the tragic circumstances surrounding Jayne's tragic death, and the implemented changes in medical procedures at Queanbeyan Hospital since her death, I have come to the view that there are no useful recommendations I could make which need to address the criticisms of Jayne's treatment on 9 March 2008. 21I make the following formal finding: I find that Jayne Elise Duncan died between 0815 and 0930 on 9 March 2008 at Queanbeyan of unexplained natural causes. Magistrate van Zuylen Queanbeyan Local Court DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 26 March 2012