DEPUTY State Coroner Evelyn Vicker found that York teenager who Andrew Allan died on September 17 2010 after being sent home from Northam Regional Hospital died of natural causes, pneumonia compounded by septicaemia.
However Ms Vicker, who delivered her findings at the Northam courthouse last Friday, said that Andrew had not received proper assessment when he was taken by his mother to the hospital’s emergency department the previous afternoon.
“Andrew’s presentation nonetheless warranted, at least, a proper assessment by proper observation. Had Andrew been referred for medical review, he could have been admitted, provided with IV antibiotics, adequate fluid support and transferred to a tertiary Perth hospital,” Ms Vicker said.
“At least in that situation Andrew’s family would feel all that could have been done, was done, and that he had an opportunity for survival.”
Ms Vicker was particularly critical of the registered nurse Sebastian Swoboda who triaged Andrew when he arrived at the hospital, diagnosed gastroenteritis and sent him home with childrens Panadol and hydrolyte.
Mr Swoboda did not at the time fill out the basic assessment form; nor did he refer Andrew to Dr Ola Jinadu who was nearby in the emergency department at the time.
Ms Vicker said she found Mr Swoboda’s recollection of events “unreliable”.
According to her, the hospital’s senior nursing staff considered Mr Swoboda needed assistance in training but this advice was not passed on.
“While confidence is a good attribute for effective decision making, over-confidence can be dangerous. In the event of uncertainty one would expect over-referral, rather than under-referral for experienced input,” she said.
Ms Vicker said the hospital and WA Country Health Service (WACHS) had tightened emergency department protocols after Andrew’s death and made a series of recommendations on emergency department procedures.
As Mr Swoboda had already been referred to the Nursing and Midwifery Board of the Australian Health Practitioner Authority, Ms Vicker did not refer the matter separately.
She concluded by offering her sympathy to Andrew’s family.
So too did a senior officer of WACHS Dr Felicity Jefferies who was interviewed after the Deputy Coroner’s finding were handed down.
She said WACHS stood ready to help the family.
“We offer our sincere apologies,” Dr Jefferies said.
“This incident has severely affected the close-knit community of Northam.
“We dismissed the nurse who didn’t do the basic things.
“WACHS will adopt all the coronial recommendations and this will mean a huge amount of changes.
“The biggest one will be triage training throughout all country hospitals.”
Perhaps coincidentally the Minister for Health Dr Kim Hames and the Minister for Regional Development Brendon Grylls have issued a statement naming Northam as one of the four regional hospitals to have a doctor ‘on the floor’ in their emergency departments and a further 12-hour ‘close call cover’ through the Southern Inland Health Initiative (SIHI).
According to Dr Hames, this would mean a doctor within 10 minutes of the hospital round-the-clock.
“SIHI’s innovative district network model means patients with urgent conditions will receive prompt medical treatment from the duty doctor,” he said.