‘Too late to save him’: Baby dies at Royal Hobart Hospital after treatment delays

A baby died at the Royal Hobart Hospital with sepsis after staff failed to treat him for six hours. FULL STORY >>

A BABY died at Royal Hobart Hospital with sepsis after staff failed to see him for nearly an hour or treat his critical condition for six hours, a coroner has found.

On Tuesday, Coroner Simon Cooper handed down his findings into the death of the baby boy, who died from a serious infection leading to multiple organ failure in September 2019, aged just 48 days old.

The baby was born two weeks’ premature with a congenital heart defect and spent six days in hospital before going home with his parents in New Norfolk.

But a few days after receiving his six-week vaccination, he became ill with a serious bacterial infection.

Mr Cooper said the baby was triaged at the Royal Hobart Hospital in a category requiring review within 30 minutes, but was not seen for 51 minutes – and even then was only seen by a first-year intern.

About 1pm on the day of his death, the baby was deemed as requiring review within 15 minutes, as needing a full children’s early warning assessment and as requiring his blood pressure to be taken.

That review and the assessment did not occur and his blood pressure was not taken until six hours later.

Royal Hobart Hospital Liverpool Street entrance. Picture: MATT THOMPSON

An emergency department consultant – not a paediatrician – also assessed the baby and considered sepsis was a possible diagnosis, with a plan to administer intravenous antibiotics.

He was reviewed under a separate process at 3pm, with the paediatric register unable to get intravenous access, with his condition deteriorating.

About 5.30pm, an x-ray was carried out, showing he had a bowel obstruction, and a decision was made to operate.

A blood test showed he had severe sepsis.

Mr Cooper said the boy was incorrectly triaged, and needed to be seen much sooner than 30 minutes, let alone the 51 minutes it took.

“His management thereafter was informed by medical staff apparently not believing that his condition required urgent or time critical treatment until about 6pm, six hours after his arrival in hospital and by which time it was almost certainly too late to save him,” he said.

“It seems that the knowledge of his congenital heart condition may have served to obscure the reality of what was happening to (the baby), that is that he was suffering from a life threatening bacterial infection.”

Mr Cooper also said there was a delay in reporting the boy’s death to the coroner for several months.

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