Boy with asthma died after being wrongly diagnosed with panic attack at Burnie hospital

The state’s chief medical officer has apologised following the hospital death of an eight-year-old boy who received substandard treatment for asthma.

The state’s chief medical officer has apologised following the hospital death of an eight-year-old boy who received substandard treatment for asthma.

Coroner Simon Cooper confirmed on Monday the little boy, who had autism spectrum disorder, died at North West Regional Hospital after his asthma was misdiagnosed as a panic attack.

Mr Cooper found the boy had told staff he had asthma, and described his death as “entirely avoidable” having been caused by “substandard medical care”.

Chief Medical Officer Professor Tony Lawler has said processes were underway to ensure a similar death didn’t happen again.

“Let me start off simply by apologising for what was a tragic death that occurred in July 2019,” he said.

“Since that time there’s clearly a recognition that there’s nothing that we can do to take that death back, so our focus has been entirely on assessing our systems and our processes to ensure that it doesn’t happen again.”

Chief Health Officer Professor Tony Lawler speaks to the media in Hobart on Monday, September 6, 2021.

Professor Lawler told those present at the Parliamentary Budget Estimates Hearing the Health service had “fully co-operated” with the coroner’s recommendations, including implementing an early warning system.

The system would observe a patient’s signs and symptoms to form a score.

Scores above six would trigger assistance from ICU staff, and a score of eight would trigger Code Blue – the highest medical emergency response.

He said oxygen compliance had improved, and the processes were subject to ongoing monitoring.

“We use CO2 detectors now on the paediatric emergency trolley within the North West regional,” he said.

“The System has learned and improved from that tragic outcome.”

Labor Leader Rebecca White has said her heart went out to the family.

“Any person hearing the story today would be utterly distraught to know that a young person who presented for health care died when they didn’t need to die,” she said.

“I think what needs to be learned from this is that we need to properly resource our hospitals to make sure that when people do present in an emergency situation they’re able to access timely healthcare.

“That coroners’ report today is a damning indictment of a government that has neglected health for far too long.”

Health Minister Jeremy Rockliff described the death as an “absolute tragedy”.

“Any parent or any person would be deeply upset by what happened,” he said.

Misdiagnosis led to little boy’s “entirely avoidable” death

AN EIGHT-year-old boy visiting Tasmania on his school holidays died when hospital staff incorrectly diagnosed his asthma as a panic attack, a coroner has revealed.

The “lovely little boy” died an entirely avoidable death due to substandard medical treatment at the North West Regional Hospital in July 2019, Coroner Simon Cooper said in his findings on Monday.

“He told those treating him at the hospital that he had asthma but they thought it was a panic attack. It was not,” Mr Cooper said.

“He should have been transferred to a hospital either in Hobart or Melbourne where he could be ventilated. Instead, he was kept at the North West Regional Hospital where he was inadequately treated, wrongly diagnosed, and died.”

Mr Cooper said the little boy, who had autism spectrum disorder, lived with his grandparents in Bendigo.

Although he was prescribed an inhaler for asthma, he had not been formally diagnosed with the condition or prescribed prevention medication.

At the time of his death, he was visiting his paternal grandparents in Ulverstone and appeared to have a cold.

When his condition worsened and he struggled to breathe, his grandmother called an ambulance and he became “markedly short of breath”.

The North West Regional Hospital . (AAP Image/Simon Sturzaker)

The boy was continually treated with Ventolin in a paediatric ward and administered antibiotics after he was diagnosed with an infection.

Then in the early hours of July 3, the boy became restless and distressed, “panicking that he couldn’t breathe”.

He was given Ventolin and was reassured, with the night staff team reaching consensus that he seemed to be having a panic attack.

At 7am, the boy collapsed with a respiratory arrest.

He was intubated and given adrenaline, but attempts to resuscitate him were of a “poor standard” and unsuccessful.

Forensic pathologist Donald Ritchie said the boy’s death was due to an acute exacerbation of chronic asthma.

A coronial division doctor said the hospital had made a diagnosis of mild exacerbation of asthma, underestimating the severity of the attack.

He said the child had need to be placed in intensive care and treated with “major interventions”, which did not occur.

“(The boy’s) death was entirely avoidable. It occurred because of substandard medical treatment,” Mr Cooper said.

In the wake of the coronial findings, the Tasmania Health Service apologised for the boy’s death.

“Since that time, our focus has been on learning from what has occurred and implementing changes to ensure that such an event does not happen again,” chief medical officer Tony Lawler said.

He said a number of changes had been made at the hospital, including an “early warning system” to ensure children were treated in ICU as required.

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