By court reporter Karl Hoerr
An inquest has found “unquestionably inadequate” management of fluids for a six-month-old boy who died after being misdiagnosed at Shoalhaven Hospital on the New South Wales south coast.
Key points:
- Medical staff at Shoalhaven Hospital failed to detect cause of Kyran Day’s illness
- Staff took three hours to arrange an ambulance to take baby Kyran from Shoalhaven to Sydney
- Coroner makes series of recommendations about hospital and ambulance training
The coroner noted the failure to detect the actual cause of Kyran Day’s illness by medical staff, who initially thought he had gastroenteritis when he was admitted in October 2013.
It was many hours later that medical staff determined the baby was suffering from a bowel obstruction and a decision was made to transport him to Sydney.
It took three hours to arrange an ambulance to transport him from Shoalhaven to the Sydney Children’s Hospital, where he later died.
The inquest findings refer to “unquestionably inadequate” management of his fluids at Shoalhaven Hospital.
The coroner has made a series of recommendations about hospital and ambulance training, and Kyran’s father Grant Day said it will hopefully mean people will be safer.
“That’s why we’ve been fighting so long. There’s some amazing doctors and nurses out there and like we said from the start, this has never been a witch hunt but we just wanted to make sure that no other family have to go through this,” he said.
“This is about everyone being able to feel safe to take their child — not even just their child but anyone — to a New South Wales hospital or a health facility and feel safe enough to trust the health system.
“Shoalhaven Hospital isn’t a small regional hospital and, regardless of that, what actually happened in our case, it wouldn’t have mattered if it was a small regional hospital or a hospital here in the city.
“What was missed, the diagnosis and everything that went with it, it wouldn’t have mattered where it was.
‘Children and babies don’t have a voice’
Kyran’s mother Naomi Day said medical practitioners need to listen more closely to what parents say about their children.
“The bottom line is that children and babies don’t have a voice. Kyran couldn’t say to me “Mum, there is something seriously wrong.” I had to be the voice for him,” she said.
“So I want all parents, grandparents and everyone to be able to feel comfortable in saying there is something wrong.
“Kyran was a beautiful baby. He was the spitting image of his dad. Always smiling, always happy.
“As you can imagine, having him there one day and then, three days later he’s brain dead, that’s every parent’s worst nightmare.
Dr Toby Greenacre, who treated baby Kyran, was cautioned after being found guilty of unsatisfactory professional conduct.
A Professional Standards Committee found he lacked attention to detail, communicated poorly with nursing staff, had poor time management and failed to prioritise the clinical needs of his patient.
The chief executive of the Illawarra Shoalhaven Local Health District, Margo Mains, issued a statement that said the findings would be “carefully considered”.
“Our internal investigation, together with HCCC (Health Care Complaints Commissions) investigations, delivered recommendations and lessons, mainly around staff education and training and transfer processes, which have now been implemented by the Shoalhaven District Memorial Hospital,” Ms Mains said.
“We will continue to support the family as they work with NSW Health agencies to ensure the lessons learned from this tragedy can make a real difference to the care of our youngest patients.”
NSW Ambulance welcomed the coroner’s recommendations.
“Progress in meeting the two new protocols recommended by the coroner is well advanced, NSW Ambulance will advise the coroner on the progress,” it said in a statement.
Baby’s mother to tell his story in training video
The NSW Health Minister Jillian Skinner welcomed the coroner’s findings and said the Government would “carefully consider all recommendations”.
“Kyran’s death was tragic. I extend my condolences to his parents, Grant and Naomi, and their family,” she said in statement.
Ms Skinner said the Day family had been working closely with the NSW Clinical Excellence Commission (CEC) “on strategies to ensure the immediate investigation of concerns raised by loved ones if a patient’s condition deteriorates in hospital”.
She said the family and the CEC were discussing ways to extend the existing REACH program that was designed to help patients and families to escalate care if they have concerns.
“Kyran’s name and photograph will be included on information posters and brochures which will be available to families of all paediatric patients on admission to hospital,” the Minister’s statement said.
“Kyran’s mother will also tell his story in a training video for NSW Health staff.”
Ms Skinner noted the coroner had not recommended any legislative changes.
This post originally appeared on ABC News.
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