Launceston General Hospital slammed for delays in diagnosis after toddler’s death

Launceston General Hospital has again come under fire after a patient’s death – this time following the tragic passing of a 19-month-old girl.

Launceston General Hospital. Picture: Amber Wilson

Launceston General Hospital has once again found itself the subject of condemnation – this time following the death of a toddler who had been in its care.

The 19-month-old girl died in June 2021 from blockage and twisting of the small intestine after her parents took her to hospital suffering pain, lethargy and vomiting.

In his findings released on Monday, Coroner Simon Cooper said it was “immediately evident” the child was “gravely unwell” upon her admission, and was triaged as category two – to be seen within 10 minutes.

The toddler was assessed under a “Children’s Early Warning Tool”, which determined her case required a number of actions, including a senior doctor review within 15 minutes, complete observations taken at least every 15 minutes and notification of the inpatient team.

The plan also deemed that if her condition didn’t improve, a senior medical officer or consultant must be notified.

“In fact, (the child’s) medical records suggest that none of this was done,” Mr Cooper said.

The girl had her first observations taken at 2.20am – then not again until 7.50am.

She was moved into the hospital’s emergency department short stay area about 3am before she was first reviewed by a doctor about 4.21am, by a paediatric registrar at 4.45am, then by the paediatric consultant at 6am.

Mr Cooper said medical imaging was requested, but not carried out for “another hour or so”.

After blood tests revealed the girl was in acute renal failure, she was transferred to the Royal Hobart Hospital (RHH) by road ambulance, arriving at 1.46pm.

The girl was in multi-organ failure by the time she arrived, and died before doctors could perform abdominal surgery.

The coroner noted the child had a “significant medical history” including a cancerous kidney tumour, but had been doing well in the lead-up to her death.

A forensic pathologist found the small intestine problem had resulted from complications from the tumour removal.

Mr Cooper said while the care the girl received at the RHH was of an “entirely appropriate standard”, the same could not be said of Launceston General Hospital (LGH) – which failed to adhere to any of the procedures mandated after the child’s assessment.

He said delays in diagnosing her bowel obstruction meant her transfer to RHH was delayed.

“I consider that the failure to transfer (the girl) to the Royal Hobart Hospital earlier may have been the difference between her survival and death.”

In response to the coroner’s findings, the LGH said a review of the girl’s treatment had been undertaken, with a view to identify system improvements – to prevent similar events occurring in the future.

The LGH’s chief executive Jen Duncan said a number of changes had already been implemented as a result, including increased paediatric medical training relating to resuscitation, audits into the way observations of children were recorded, and how their cases were escalated.

The LGH has come under repeated criticism in recent years over numerous patient deaths.

In September 2020, several of Tasmania’s most senior doctors pleaded for urgent action to improve the LGH’s standards, saying it was “unsafe for patients” and that “patients have died unnecessarily”.

The hospital was also extensively scrutinised in last year’s child sexual abuse commission of inquiry hearings, after revelations a paedophile worked on the children’s ward for 18 years.

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