Coroner finds death of baby Logan Scott Fergusson at Women’s and Children’s Hospital ’potentially preventable’

A six-week-old baby died in the WCH when his oxygen levels dropped after doctors decided to put off a procedure until the morning, a coroner says.

A “brave but very sick” six-week-old baby should have had his care at the Women’s and Children’s Hospital escalated sooner, after his oxygen dropped to dangerously low levels, a coroner has found.

In findings handed down after an inquest into the death of baby Logan Scott Ferguson, Deputy State Coroner Ian White found his 2016 death was “potentially preventable” but was unable to say “with certainty” it was preventable.

Logan was born on April 29, 2016, with a serious heart defect and was flown to the Royal Children’s Hospital in Melbourne for heart surgery in his first week of life. He returned to the WCH about a month after surgery and was discharged on June 3, 2016.

Logan Fergusson at just a few weeks old, before he died from heart complications in 2016. Picture supplied by family.

The inquest heard last year that Logan returned to the WCH emergency department on June 14, 2016, with oxygen levels between 65-73 per cent but an echocardiogram – which checks how blood pumps through the heart – was not ordered until the next morning.

Doctors had set a low of 65 per cent for Logan’s accepted oxygen saturation levels, which were monitored overnight. Of the 18 recordings taken, 13 fell below the 65 per cent mark, including one as low as 40 per cent.

A healthy person should have an oxygen saturation level of 95 per cent or more.

An echocardiogram the next morning revealed a narrowing of his left pulmonary artery requiring further surgery. However, he deteriorated and stopped breathing soon after 11am on June 15, 2016.

Logan Fergusson died at just six weeks old. Picture supplied by family.

Logan Fergusson with his mum Celeste Fergusson. Picture supplied by family.

His cause of death was determined as hypoxia and reduced pulmonary perfusion complicating congenital heart disease.

In his findings, Mr White said it would have been “preferable” that Logan had the echocardiogram on the night he presented to the emergency department.

“I find it was likely that an echocardiogram would have likely identified the narrowing of the left pulmonary artery if it was performed earlier,” he said.

He said a nurse on duty overnight, who had sought a medical referral when Logan’s oxygen levels dropped to 45 per cent, should have again “notified a medical officer” about the low levels during the night despite them being “transient”.

Celeste Fergusson outside the coronial inquest into the death of her baby Logan. Picture NCA NewsWire Emma Brasier.

Mr White also found that “if Logan had not deteriorated suddenly at 11am there was still a significant risk of not being able to stabilise him appropriately for the surgery at RCHM”.

He said there was also no evidence the surgery would have been successful.

Mr White also said the concerns of Logan’s parents were “understandable and appropriate” and “did warrant a further medical review”.

“Certainly Logan was a very sick little boy. If more was done earlier in terms of elevation of care through empirical therapies, then he had a better chance of being adequately stabilised for a retransfer to RCHM.”

But, he said he could only find Logan’s death was “potentially preventable” and “cannot say with certainty whether Logan’s death was preventable”.

He did not make any recommendations because he said an issue raised during the inquest about observation recordings was rectified last year by SA Health.