The loving son of Kim Mackin and Daniel almond, named Troy almond, was born on 9 October 2014, and according to his parents, the boy was a happy and joyful kid almost always. He also uses to play and chase with his two other brothers. These were the eloquent statements of the child's parents at the inquest. His mother further told that he dropped his two elder sons at the school and brought Kim to the hospital. According to the coroner's act 2009, the coroner must provide pieces of evidence of how, where and when the person died and what are the causes of the death. Hence, in Troy's case, the coroner was able to gather enough shreds of evidence so that he was able to answer all these questions. The inquest was conducted to tell Troy's family how and why their child died and what decisions should have been made by the hospital and the inquest also provided precautionary that may help prevent deaths in the future. After Mr Tajwid's first assessment of the boy Troy, the reviews were written a little later, and these observations had some vital signs that showed that these were the last set of statements. Dr Tajvidi diagnosed that the boy was suffering from viral disease. The key document of the inquest was paediatric sepsis, and in this child's case, the vital signs were entered into the system without being late and during the investigation of the case (Farrel & Nadel, 2016). It was also highlighted that parental concern is also an essential part of the case. Under all the policies of the case, it was found that troy had a bacterial infection that was cure able only if there existed the early detection and early demonstration of antibiotic therapy to which microorganisms were treatable.
Troy was well till 21 march 2016. At about 12.30, his mother noticed that he was restless with a high temperature and refused to breastfeed. Hence, his mother gave him a paracetamol dose, which he vomited. She took troy to the hospital, and the demonstration started. It was told to Troy's registered nurse Mason by his mother that he was a healthy baby born without any abnormalities. After taking the history and demonstration, the registered nurse recorded them, and she observed that the boy was lethargic and restless, not able to tolerate food but was only able to drink water and breast milk. The registered nurse also recorded that the boy had an elevated pulse rate and the temperature
The case was handed over to Dr Babak Tajvidi and another registered nurse, Shaun Avis, in charge by the first nurse, and according to the dosing chart, troy was given Panadol. After the sometime doctor examined the boy, he noted everything normal physically apart from the pharyngeal redness (Schlapbach, 2019). After some time the registered nurse again took the observations of the child and recorded that the boy's condition was increasing to be unstable so she informed the doctor so after some time his blood sample was taken so that they do blood test and after some time for a while his situation was bit stable but later the doctor noticed a rash on his chest and back and registered nurse recorded that the rash was non blanching but the during the corners investigation the Dr tajvidi gave the evidence that the rash was blanching in its appearance and after questioning the coroner found that doctor tajvidi agreed on the oral evidence which he should not have believed them before reviewing and examining the boy again and during the investigation the doctor admitted that the child should have been challenged also even if he was becoming stable and he should have went through his blood tests and before taking full observation the doctor diagnosed him with some viral illness and he discharged him without doing any further investigation and the mother of the boy also stated that the boy was happy and smiled at her at the time of the discharge and she also said that she had conversation with the doctor and the nurse that she'll inform them about Troy's condition as they were concerned
The coroner investigated that the witnesses agreed that there was an improvement in Troy's condition. He also noted a difference in the shreds of evidence by the Registered nurse and the doctor.
This day the boy woke up more restless and unwell, and his temperature was increasing rapidly with the increase, and he was vomiting. His parents called the ambulance, and he was taken to the hospital, and he was rescued by Dr glen and Dr peter. Still, unfortunately, the resuscitation was unsuccessful, and doctor Thompson told this to the deceased person's family, and his death cause was unknown.
24 march 2016, the forensic pathologist conducted a post mortem, which resulted in septicaemia caused by streptococcal infection.
The three expert physicians were called who gave their initial reports and the oral pieces of evidence at the inquest. One of them reported that at the beginning, troy was having a high heartbeat, which is a sensitive indicator, and the other one stated that the vital signs were insufficient for discharging troy too soon (Maddux & Douglas, 2015). The third one, Dr Golding, gave the evidence that after improvement in Troy's condition, it was not necessary to do blood tests. The shreds of evidence of the other two physicians were also valid. All of the experts agreed that there was some severe bacterial infection, and its treatment requires blood tests initially.
This sepsis pathway concerns the clinicians' high-level parental concern when finding the factors of the risk for sepsis, and it also directs the doctors and registered nurses to observe the vital signs falling into the red and yellow zones with their standard observations chart. After the observation, Troy's heart was in the red zone, which means it was on the borderline and temperature in the yellow one. So the emergency department expert professor Kelly gave the evidence that the parental concern should not only be held accountable or sway away from the clinicians away from the case (Long & Shan & Pearson, 2013). But Mr Golding said that parental concern about the child plays an important role. If the fears of the parents are high, the clinicians may get pressurized that the child may look okay but are not well otherwise . the coroner accepted the pieces of evidence of the experts.
25 September 2018, professor Kesson the expert in paediatric infectious diseases, microbiology and virology she practices at the children's hospital in Westhead. According to her, Troy's bacterial infection was probably contracted from colonizing streptococcus pyrones in his nose and throat. A microorganism and no vaccine caused this infection until now were available for protection against disease from this microorganism. Professor Kesson stated that the white body cells in Troy's body were increased (Long & Duke, 2016). Some other infectious issues and her shreds of evidence were accepted by the coroner. Professor Kesson's pieces of evidence showed that this bacterial infection was treatable if the early detection and the first administration were held. The professor also stated that the streptococcus pyrones are sensitive to several antibiotic medicines, and she also concluded that if blood tests were done earlier, it was easy to detect the bacterial infection and could have been cured by antibiotic therapy and the death of the child could have been prevented, and the coroner accepted these (Lu & Tian & Sun, 2014).
The procedures and the protocols helped in detecting the bacterial illness at the hospital, and it received attention in the course of this inquest
The management policy carries information for educating the staff of the hospital and compliance audits. The BTF approach towards the clinical assessment of the patient requires a coded colour chart is used to record and observe the patients vital signs. These charts establish sets of parameters for recognizing the patient's condition, which might be worsening and helps the doctors and clinicians in charge to identify which action must be taken. At Troy's presentation, the admission to the paediatric ward was required, the paediatric nurse had to enter the Last set of observations on the paper on the topic document, which transfers the patient to the paediatric ward, and the registered nurse did not use the BTF approach in examining and observing troy the nurse only used iView approach for observations and the iView field did not provide any colour codes alerts and other sign that the vital signs were very high (Pain & Green & Dough, 2017). The doctor Tajvidi also gave the pieces of evidence based on the iView approach. It was necessary to open another screen by selecting the coded bit chart. Troy's observations were only seen in the iView field. And the registered nurse in charge did not directly enter the comments in the colour code chart that was mandatory to take the observations in the BTF approach. The registered nurse admitted that he used the iView approach as it was easy to take the patient's comments. Still, there were no pieces of evidence found that other paediatric nurses also only used the iView approach and also there is no evidence that the practice was extended beyond some staff (Bhonagiri & Lander & Green, 2020).
The document was updated. The sepsis pathway is a document that helped in the recognition and management of patients who are clinically deteriorating, and they did not get evidence that this document was mandatory.
In the light steps taken, it is recommended that the hospital should continue the education of their staff and do orientation and the training concerning BTF and sepsis as appropriate. Keeping in consideration all documentary evidence and oral evidence heard at the inquest. And now, the coroner can confirm that the cause of the death was septicaemia due to streptococcal infection, and troy died due to failure by the specialist in the emergency department at the Shoalhaven district memorial hospital.
Thanks to the counsel assisting and her instructing solicitor and Ms Kate from the crown solicitor office for the tremendous amount of the assistance they provided to the coroner and the coroner also expressed his gratitude to Troy's family, Kim and Daniel, who became the part of an inquest and attended it regularly he had no words to comfort them but the best he could do was to acknowledge the enormity of their loss and their love for their beautiful son and their dignity and the participation throughout the coronial process was so admirable and humble.
Bhonagiri, D., Lander, H., Green, M., Straney, L., Jones, D., & Pilcher, D. (2020). Reduction of in-hospital Cardiac arrest rates in Intensive care equipped NSW hospitals in association with Implementation of Between the Flags Rapid Response System. Internal Medicine Journal.
Farrell, D., & Nadel, S. (2016). What’s new in paediatric sepsis. Current pediatrics reports, 4(1), 1-5.
Long, E. J., Shann, F., Pearson, G., Buckley, D., & Butt, W. (2013). A randomised controlled trial of plasma filtration in severe paediatric sepsis. Critical Care and Resuscitation, 15(3), 198.
Long, E., & Duke, T. (2016). Fluid resuscitation therapy for paediatric sepsis. Journal of Paediatrics and Child Health, 52(2), 141-146.
Lu, S., Tian, J., Sun, W., Meng, J., Wang, X., Fu, X., ... & Zhou, L. (2014). Bis-naphtho-γ-pyrones from fungi and their bioactivities. Molecules, 19(6), 7169-7188.
Maddux, A. B., & Douglas, I. S. (2015). Is the developmentally immature immune response in paediatric sepsis a recapitulation of immune tolerance?. Immunology, 145(1), 1-10.
Pain, C., Green, M., Duff, C., Hyland, D., Pantle, A., Fitzpatrick, K., & Hughes, C. (2017). Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System. International journal for quality in health care, 29(1), 130-136.
Schlapbach, L. J. (2019). Paediatric sepsis. Current opinion in infectious diseases, 32(5), 497-504.
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