Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4
I, Rod Chandler, Coroner, having investigated the death of
Ella Kristy MOORE
WITHOUT HOLDING AN INQUEST
FIND THAT :
Ella Kristy Moore ("Ella") died on 25 January 2008 at the Royal Hobart Hospital, Liverpool Street in Hobart ("the RHH").
Ella was born at Burnie on 9 September 2006 and was aged 16 months.
I find that Ella died as a result of hypoxic brain damage due to lymphocytic myocarditis.
At the time of Ella’s death she was in the care of medical practitioners at the RHH.
CIRCUMSTANCES SURROUNDING THE DEATH :
Ella lived with her parents, Michael and Kristy Moore at their home. On Wednesday 23 January 2008, Ella appeared unwell. She had a runny nose, a slight cough and quickened breathing. Mrs Moore arranged for her to be seen that day by a Smithton medical practitioner, Dr Nicole Anderson.
Dr Anderson reports that she was informed by Mrs Moore that Ella had been vomiting nightly for the previous three nights and that she had "some grunting breathing" associated with the vomiting. She had also been coughing and exhibited some mild lethargy. In fact Ella vomited again while she was in Dr Anderson’s rooms. After her examination, Dr Anderson concluded that Ella was possibly suffering from a lung abnormality. In her opinion Ella required further assessment at the North West Regional Hospital ("the NWRH") in Burnie. Because of her history of vomiting arrangements were put in place to convey Ella that day to the NWRH by ambulance.
On arrival at hospital Ella was examined by locum Paediatric Registrar Dr Sing-Jill Chow. Ella was noted to be experiencing moderate respiratory distress with slightly reduced air entry bilaterally. At this time she was well perfused, mildly dehydrated and was noted to have good pulses peripherally. X-rays revealed increased bronchovascular markings and a prominent hilar shadow on the right side. Cardiomegaly (enlarged heart) was evident on x-ray but significantly, this was not detected by medical staff at this time. On the basis of her initial findings, Dr Chow made a provisional diagnosis of possible asthma or pneumonia with either viral or bacterial aetiology. At 3.00pm Ella was admitted to the children’s ward and treatment commenced with intravenous fluids, salbutamol nebulisations, humidified oxygen and intravenous antibiotics.
At about 7.00pm on 23 January it was noted that Ella’s respiratory distress had worsened and that she also had a fluctuating respiratory rate. She was reviewed by Dr Chow and then by Staff Specialist Paediatrician Dr Amol Daware. At this time Ella had mild sweating on her face but her extremities were warm and she was still maintaining oxygen saturations of 96 – 98% with an oxygen mask held an inch away from her face. She appeared lethargic but no abnormal heart rate on the pulse oximeter monitor was noticed. She had bilaterial scattered wheeze on auscultation. On the assumption that Ella’s condition was explained by asthma a plan was made to give her continuous salbutamol nebulisations and humidified oxygen to maintain saturations above 90%. At about 9.00 pm Ella was again reviewed by Dr Chow. She still appeared to be in moderate respiratory distress with an audible wheeze although maintaining oxygen saturations above 90% with good perfusion. She seemed quite exhausted.
At about 9.30pm Ella had a venus gas sample taken which revealed mild metabolic acidosis. A decision was taken to give a salbutamol IV bolus and the clinical scenario was discussed with Dr Bob Stolk, the on-call anaesthetist with a view to shifting Ella to ICU for monitoring and potential mechanical ventilation. At this time the clinical scenario was also discussed with Dr Simon Parsons, a Paediatric Intensive Care Specialist at the RHH. He suggested continuing salbutamol infusion with an elective intubation and ventilation. He also suggested a trial of aminophylline. He agreed to put in place arrangements for Ella’s transfer by the Paedriatic Emergency Transport Service (PETS) to the RHH.
Ella was moved to the Intensive Care Unit at about 10.30pm. Up to this time she had had continuous electrocardiogram and blood pressure recordings which seemed satisfactory. They did not indicate any abnormal heart rate or rhythm. At about 11.30 pm Ella was transferred to the operating theatre for intubation. She was anaesthetised using a gas induction (sevoflurane and oxygen). On the first intubation attempt a large amount of stomach contents were regurgitated into the upper airway with associated laryngospasm. A muscle relaxant was administered and bag and mask ventilitation was initiated. At this time bradycardia was noted. Intubation on the second attempt was successful and was completed about 3 minutes after the first attempt However, the bradycardia persisted with her heart dropping to below 60 beats per minute. The electrocardiogram monitoring showed a rhythm of second degree heart block. Ella immediately received positive pressure ventilation and cardiopulmonary resuscitation. ("CPR") Antropine 20mcg IV and adrenaline 100 mcg IV along with a fluid bolus of normal saline were given. The record of Cardiac Arrest indicates that approximately 30 minutes elapsed from the time of cardiac arrest to the return of sinus rhythm and cardiac output.
In readiness for her transportation to the RHH, Ella had a femoral venous line inserted and received multiple doses of sodium bicarbonate. She was continued on a normal saline infusion and had repeated venous gas samples. At this time her blood pressure was noted to be variable. She had a therapeutic hypothermia induced and left theatre at about 4.00 am to be flown to the RHH.
On arrival at the RHH, Ella was noted to be in an induced therapeutic hypothermic state. She was un-responsive to painful stimuli with no spontaneous movements. Brainstem responses were absent and her pupils were fixed and dilated.
The signs of brain death were noted to persist on 25 January 2008 when Ella was taken off all sedative drugs and after rewarming to normothermia. Intensive care support was withdrawn with parental consent and Ella died at 12.30 pm on 25 January 2008.
Shortly after Ella’s death a post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. The cause of death in Dr Lawrence’s opinion was hypoxic brain damage due to lymphocytic myocarditis which in his view was probably post viral. Dr Lawrence did not detect any "convincing evidence of asthma".
Dr Antonio DePaoli is a Staff Specialist in Neonathology in the Neo-Natal and Paediatric Intensive Care Unit (‘NPICU’) at the RHH. Dr DePaoli has provided a report into the circumstances surrounding Ella’s death. In that report Dr DePaoli makes these comments:
"Death due to lymphocytic myocarditis is certainly not inevitable but can occur, even if the diagnosis is made early. ‘Classically, it is thought that one third of patients with acute viral myocarditis recover normal cardiac function, one third show signs of chronic heart failure, and one third either die or require heart transplantation’. From: Wheeler DS, Kooy NW. "A formidable challenge: the diagnosis and treatment of viral myocarditis in children." Critical Care Clinics. 2003 Jul;19(3):365-91.
There were factors contributing to Ella’s death which in retrospect may have been avoidable:
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Prior to the cardiac arrest Ella’s heart failure (as the cause of her respiratory distress) was diagnosed as asthma. The history and some of the clinical findings as detailed in the transfer letter from the NWRH (e.g.grunting with absence of wheeze despite ‘equal air entry bilaterally’) are not consistent with a diagnosis of asthma, although she was noted at times to have a wheeze on the paediatric ward. Whilst myocarditis causing heart failure in this age group can mimic respiratory illness (e.g. bronchiolitis, asthma), the abnormalities on her chest x-ray taken before the cardiac arrest (i.e. cardiomegaly, bilateral pleural effusions and hazy lung fields), are consistent with heart failure. It is unclear from the correspondence whether this chest x-ray was reviewed by a senior member of the medical staff at the NWRH. The failure to diagnose heart failure led to Ella’s inappropriate treatment with salbutamol and precluded earlier appropriate treatment directed at her heart failure.
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With the potential for unwanted side-effects, especially in the presence of cardiac disease (e.g. arrhythmia and hypotension), the use of sevofluorane as an induction agent for intubation in paediatric emergencies is appropriate only in those conditions where the upper airway is considered critically compromised (e.g. croup, epiglottitis). The use of sevofluorane and the difficulty intubating at the first attempt, in the presence of underlying unrecognised severe heart failure, most likely precipitated the loss of cardiac output for a period long enough to cause catastrophic hypoxic-ischaemic brain injury."
The circumstances of Ella’s death were reviewed by the State’s Paediatric Mortality and Morbidity Sub-Committee (‘the Committee’). It noted that the staff at the NWRH were confronted with an "unusual and catastrophic illness outside their usual scope of practice." However, it considered that errors were made by staff at the NWRH in the medical management and diagnosis of Ella’s condition and that those errors have been accurately identified and documented by Dr DePaoli. The Committee observed that the outcome for Ella may not have been different even if she had been correctly diagnosed at an earlier time.
The Committee has made several recommendations, these being:
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that consultation with the NPICU team in Hobart should occur early in the course of any child’s deterioration in a peripheral hospital, with a view to earlier retrieval to Hobart (or Melbourne if appropriate).
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that critically ill children should ideally be retrieved to the NPICU by experienced staff prior to deterioration to intubation, if practically possible.
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Statewide digital x-ray infrastructure allowing immediate sharing of x-rays with other hospital departments around the State should be considered as an essential development along with improved teleconferencing facilities between the RHH and the peripheral hospitals within the State.
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that there be only one hospital in the NW region so as to maximize the experience and expertise of the health care staff of that region.
COMMENTS AND RECOMMENDATIONS:
I am satisfied that a thorough and detailed investigation has taken place into Ella’s death and that there are no suspicious circumstances.
I find that Ella died as a result of hypoxic brain damage due to lymphocytic myocarditis.
I am satisfied that the failure by the medical staff at the NWRH to recognise that Ella was suffering from a heart condition, namely lymphocytic myocarditis and not from a respiratory condition was a factor which significantly contributed to this death. Because of the incorrect diagnosis Ella did not receive treatment appropriate for the management of her heart failure. However, I do acknowledge that lymphocytic myocarditis is a particularly serious condition and that it can cause death even when diagnosed at an early stage and properly treated.
I also find, accepting the opinion of Dr DePaoli, that it was inappropriate for sevofluorane to have been used as an induction agent for Ella’s intubation. Its use coupled with the initial failure to intubate a young child with underlying heart failure were factors which together most probably precipitated Ella’s loss of cardiac output bringing about the hypoxic-ischaemic brain injury which in turn caused her death.
I accept that the identification of the true cause of Ella’s condition represented an exceptional challenge to the medical team at the NWRH, which as a regional or peripheral hospital within the State is not equipped with the level of specialist expertise and other resources available at the larger hospitals, most particularly the RHH. It is, in my view, incumbent upon the health care system to put in place policies and practices designed to ensure, as far as is practicable, that seriously ill persons, particularly infants, have ready access to the best available medical services whatever their place of residence within the State. In this context I strongly support each of those recommendations made by the Committee which I have set out above.
I conclude by conveying my sincere condolences to Ella’s family.
DATED : Tuesday 17 June 2008 at Hobart in the State of Tasmania.
Rod Chandler
CORONER