An inquest has been held into the death of a four-year-old boy.
An inquest has been held into the death of a four-year-old boy. Contributed

Boy, 4, died after medical staff 'failed' to treat him

A CORONER has handed down recommendations after finding medical staff "failed" to treat a critically ill four-year-old boy with special needs urgently enough.

The circumstances around the death of Shaun Bell, 4, were the subject of an inquest, the findings of which were handed down by Deputy State Coroner Elizabeth Ryan this week.

The inquest considered a range of factors, including the telephone-based assessment advice line 13 Health, the Tweed Hospital Emergency Department and the Tweed Hospital's Paediatric Department after Shaun passed away at the hospital about 4pm on March 14, 2016.

Shaun's mother first took him to a GP on March 9, before first calling 13 Health, which is operated as part of the Queensland Health Contact Centre, on Friday, March 11.

He had been lethargic, was not eating and had previously vomited.

She explained her son was "a non-verbal special needs child", and the nurse who suggested ways of offering Shaun drinks and to wait a few days, then see a doctor if he did not improve.

Shaun's mother took the family to Kingscliff on the Tweed Coast that weekend, "hoping this would improve Shaun's condition", the court heard.

But he did not improve. He still wasn't eating, had lost weight and at 5pm on the Sunday, she phoned 13 Health again before being advised to take her son to the nearest hospital.

At The Tweed Hospital, Shaun was seen "almost immediately" by a triage nurse, whose assessment and triaging was found to be "timely, adequate and appropriate" by experts in the inquest.

A doctor saw him soon afterwards and several more doctors became involved, including the on-call paediatric senior doctor.

The senior paediatric doctor determined Shaun "did not need to be transferred to a specialist hospital with higher level paediatric services" as he believed there was "a possible cause of gastroenteritis and dehydration for Shaun's signs and symptoms", the court heard.

Shaun's condition didn't improve and when another doctor went to review him about 12.45pm on March 14, he was "unrousable, with cold hands and feet" and the doctor "immediately called a rapid response".

Shaun went into cardiac arrest and CPR was later rushed to emergency surgery, but his condition continued to deteriorate.

His cause of death was found to be peritoneal sepsis, caused by a perforated ulcer.

Ms Ryan said "none of the expert witnesses was critical of the failure to diagnose Shaun's perforated ulcer, given the rarity of this condition in young children".

"The focus of their criticism was the failure of clinicians to appreciate that he was critically unwell, and to take urgent action to identify and treat the cause of his illness," she said.

Ms Ryan stressed "medical diagnosis and treatment is a human activity, and mistakes do occur" and that coroners must "be mindful of the risk of hindsight bias" but said all medical experts identified "features of Shaun's care that were inadequate and inappropriate".

"They were unanimous that underlying these deficiencies was a shared failure to appreciate how critically ill he was, resulting in a failure to act with urgency to identify the cause," she said.

"The experts were at pains to emphasise the collective nature of this failure however, with all agreeing it would be inappropriate to single out individual clinicians for blame."

The court heard all the doctors involved "seemed to be good doctors" but had "nevertheless failed to recognise from Shaun's whole clinical picture how seriously ill he was, and to treat him accordingly".

Ms Ryan recommended Queensland Health consider further training of 13 Health nurses and that those nurses report to their manager when informed a patient is a child with a developmental delay.

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