THEY SAID IT WAS A PANIC ATTACK
Asthmatic boy died after hospital misdiagnosis
THE state’s chief medical officer has apologised following the hospital death of an eight-year-old boy whose asthma was incorrectly diagnosed as a panic attack.
The “lovely little boy” died unnecessarily because of substandard medical treatment at the North West Regional Hospital in July 2019, Coroner Simon Cooper said in his findings on Monday.
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 Tony Lawler said processes were under way 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.
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.
THE state’s chief medical officer has apologised after the hospital death of an eightyear-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 in Burnie 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 Tony Lawler on Monday said processes were under way 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.”
Professor Lawler told a 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 set off a 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,” Professor Lawler said. “The system has learnt and improved from that tragic outcome.”
Mr Cooper said the little boy lived with his grandparents in Bendigo, but was visiting his paternal grandparents at Ulverstone on his school holidays.
“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.”
Although he was prescribed an inhaler for asthma, he had not been formally diagnosed with the condition or prescribed prevention medication.
The boy had a cold and when his condition worsened and he struggled to breathe, his grandmother called an ambulance and he became “markedly short of breath”. 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 adrenalin, 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 child had needed 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.
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.
“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.