Coronial report details how Matilda Armstrong died in emergency department at Geelong hospital

A 12-month-old from Charlemont died after she started to turn blue in a waiting area of Geelong hospital’s emergency department.

Matilda Armstrong

A baby girl died in the Geelong hospital emergency department after she was not treated within the recommended time, a coronial report has revealed.

Matilda Ruby Armstrong was taken to hospital with respiratory illness and was triaged as category three — which requires medical review within 30 minutes — on July 4, 2022 at 8.54pm

But just over an hour later Matilda, who was still yet to be seen, was unresponsive in the waiting room of Geelong hospital.

The Charlemont 12-month-old was declared deceased at 11.18pm after staff were unable to revive her.

In response to the tragedy, Barwon Health has implemented a number of recommendations, including constructing a children’s ED and increasing the number of nurses in the ED.

The coroner’s report revealed Matilda had only been discharged from hospital a day before her death.

Parents Adrianne and Bradley Armstrong took Matilda to Geelong hospital on July 3, 2022 after she tested positive for Covid a few days earlier.

The registrar’s impression was that Matilda’s signs and symptoms were consistent with Covid.

Matilda was prescribed paracetamol and ibuprofen and a trial of oral fluid rehydration and was discharged with a plan to continue medication.

The following night Matilda and Ms Armstrong attended the ED and hospital staff noted she had deteriorated.

Matilda Armstrong

About 10pm, Matilda began to deteriorate with increasing respiratory distress and began turning blue.

Matilda’s mother pressed the “nurse call” button on the wall of the waiting room, and a bystander ran out to seek help from staff.

At 10.09pm, two nurses arrived and found Matilda unresponsive.

They took Matilda immediately into the ED and alerted other staff.

Staff tried to revive Matilda but she was declared deceased at 11.18pm.

An emotional Ms Armstrong told the Geelong Advertiser the past two and a half years had been difficult.

“It’s obviously not a circumstance that’s easy to go through, and then find your feet after, it’s not something either that a lot of people understand,” she said.

“She (Matilda) was just the most loving and warm child … just a very funny and cheeky girl.”

Forensic Pathologist Dr Heinrich Bouwer concluded the medical cause of death was from natural causes and was formulated as a viral respiratory tract infection and a recent Covid infection.

Matilda Armstrong

Barwon Health and an independent expert from the Royal Children’s Hospital recommended that the hospital review the emergency department waiting area and redesign the patient and carer escalation process.

They also suggested creating a care model with clear clinician oversight in the waiting room to actively monitor patients who exceed their triage waiting times.

Geelong hospital has increased the number of nurses in the ED, and their responsibilities now include initiation and reassessment of care for patients in the waiting room, including those who have breached their triage category waiting times.

Coroner Katherine Lorenz wrote Matilda’s initial and subsequent presentations to the hospital’s emergency department featured delays in time to assessment and treatment.

However, this was not identified as a potential preventable factor in the analysis by Barwon Health.

“I consider that timely assessment and treatment within expected triage time frames would have been Matilda’s best chance of survival,” Ms Lorenz said.

Originally published as Coronial report details how Matilda Armstrong died in emergency department at Geelong hospital