Outdated medical communication methods questioned after inquiries into the death of baby

The medical community has been urged to embrace modern communication technology following the devastating death of a 17-month-old boy.

The medical community has been urged to embrace modern communication technology following the devastating death of a 17-month-old boy.

On November 25, 2019, the child, referred to as Master T in a Coroner’s report, was discovered unresponsive by his mother, who noticed his leg was “cold and hard”.

Coroner Sarah Gebert’s investigation revealed Master T’s cause of death was chronic bronchial asthma, but medical mismanagement played a role in the tragedy.

It was discovered that healthcare providers failed to effectively communicate the prescribed medication for the infant when he sought treatment at different medical facilities.

The Royal Children’s Hospital sent a fax to Northern Health summarising the baby’s discharge plan, which included the prescription of the asthma drug “Montelukast”.

However, this fax was overlooked by Northern Health and Master T’s general practitioner Saeid Bahrami of the Roxburgh Park Superclinic.

While the report acknowledged the drug may not have saved the child’s life, Coroner Gebert emphasized the significant issue of relying on outdated communication methods, specifically fax machines, in the medical field.

Dr Bahrami admitted to an oversight due to Master T’s immediate transfer from Royal Children’s Hospital to Northern Health.

Northern Health claimed not to have received the fax, despite evidence in the Royal Children’s Hospital’s fax logs showing its successful transmission.

Northern Health acknowledged the problems associated with using fax machines for medical correspondence and expressed a commitment to phasing out this antiquated system.

“We are acutely aware of the potential management issues that arise from poor or missed communication between medical practitioners and health services,” the health service told the coroner.

“Northern Health Specialist Clinics have been working with GPs within our catchment to phase out the use of referral by fax and encouraging them to use electronic smart forms.

“While we are able to exercise some control over how we receive referrals from GPs, it does not have any meaningful control of the greater health system, including health services and hospitals.”

In response to the incident, the Royal Children’s Hospital conducted an independent review, identifying several issues with the use of fax machines to communicate patient information.

They highlighted the risk of information not being received, even when the sender’s fax machine indicated a successful transmission.

The hospital emphasized the need for the Department of Health to lead the transition away from fax machines, as their privacy policy does not permit the use of email for patient information.

Experts and previous coronial recommendations have also criticised the continued reliance on fax machines, describing them as “antiquated and unreliable”.

“It is apparent that despite RCH doing everything necessary to communicate to TNH...the communication through facsimile (fax) to TNH did not achieve its intended outcome,” Ms Gebert said in her report.

“I am directing that this finding be provided to Safer Care Victoria, to consider whether it is appropriate for health services to review channels of communication in the light of the potential issues which may raise with the use of facsimile as an effective forms of communication in a medical setting and it’s potential for harm being caused.”