Tommy lived with his mother Louisa and his sister Imogen aged 8 years in a large regional town of Grantham. Tommy and Imogen regularly saw their father Daniel and both parents contributed to the
care and upbringing of both children. The parents had separated only two months prior to this event. Daniel and Louise’s mother Leanne were Registered Nurses who worked in the Emergency Department
at Grantham Regional Hospital (GRH). Tommy had been a healthy and active young boy until the time of his illness. As is quite common in rural and regional towns, Tommy was well known to the staff
at the local hospital on a social level due to the fact that his father and grandmother both worked at the facility and many of the staff had known Tommy and his sister since birth. The following
is an account of the events that led up to the death of young Tommy and are provided for your information.
Tommy, a six year old boy, presented to the Emergency Department at 12.45 pm on the 16th September at a large regional hospital. Bobby was diagnosed as being in a serious condition as a result of
scarlet fever complicated by pneumonia. By 0100 hrs on the 17th September, Tommy was pronounced deceased. The coroner found that the cause of death was septic shock.
Tommy presented to the Emergency Department at GRH on the 14th September 2010 on a social visit with his father Daniel. Louisa had told Daniel that Tommy had been unwell for a few days and that
Tommy had been exhibiting flu like symptoms had developed a bright red rash over his body and that he should take Daniel to see a doctor. Tommy had been kept at home from school and Daniel reported
that his son had spent a lot of time on the couch, unwell which was out of character for this normally energetic little boy. Daniel was reluctant to have Tommy reviewed as he did not want to go
through the formal processes as he was fairly confident that Tommy only had a viral illness. After encouragement from other staff Daniel asked for one of his colleagues Dr Camden to ‘have a look’
at Tommy. Dr Camden was asked to see Tommyby a senior nurse manager.

Dr Camden acceded that this was not her normal practice to see patients that were not registered within the system. As Tommy was not triaged, no documentation was commenced at this time. On
examination Dr Camden noted that there was a rash present, no history of fever, headache, vomiting, sore throat or respiratory tract symptoms and that Tommy was eating and drinking well and passing
urine. Daniela took his sons temperature and told Dr Camden it was 37 degrees. No observations were recorded although Dr Camden indicated in her statement to the coroner that temperature and pulse
rate and oxygen saturation were within normal limits. Tommy had a blanching rash over his face, limbs and trunk and had been scratching his forearms and thighs but the rash did not feel like
sandpaper. Dr Camden diagnosed that Tommy had a viral illness or possibly scarlet fever or tonsillitis and wrote a prescription for oral Penicillin 150 mcg to be given four times per day. Dr Camden
offered to fill this prescription from the hospital stores but Daniel declined saying he would get the prescription filled if Bobby became more unwell and that he would pass the prescription on to
his mother Louisa.
15th September – 12.30pm

On the 15th September Daniel returned Tommy to the care of his mother at about 12.30pm and advised her that Tommy had seen Dr Camden who thought he had a viral illness and he gave her the
prescription to fill if she thought Tommy might need it. Due to the strained relations between the parents Daniel only provided Louisa with minimal information about the consultation with Dr Camden
the day before.

Tommy remained unwell for the rest of the day. Louisa rang GRH to find out what was wrong with Tommy and was told that they would ring her back when the notes were found. Leanne also rang GRH and
spoke to Dr Redfern who tried unsuccessfully to find notes of the consultation from the previous day

15th September at 1545hrs
On the 15th September at 1545hrs, Louisa returned her son to the Emergency Department with a high temperature, a rash, an elevated pulse rate and a moist cough. He was admitted under the care of Dr
Redfern who was a general practitioner with visiting rights at the Emergency Department. As the nurse was busy at the time, Leanne who was not on duty, took Tommy’s temperature which was 39.7
degrees, pulse which was 158 beats per minute, oxygen saturation which was 98% and recorded them in the departments notes. Leanne did not take a blood pressure or respirations as she did not have a
watch.

At 1600 hours Dr Redfern examined Tommy and a chest x-ray and mid-stream urine was ordered. No other abnormalities were noted on examination. Dr Redfern finished his shift at 5pm and asked Dr
Camden to review the x-ray before discharging Tommy home in to the care of his mother. The urinalysis taken by the nurse showed specific gravity of 1030 and pH of 5. At 1640 hours a chest x-ray was
taken in the radiology department. The x-ray department officially closed at 1630 hrs. Dr Dargan(radiologist) did not view the image until the next morning at 0700 hours.

Dr Camden reviewed the x-ray at 5pm and considered this normal as there were no respiratory symptoms that were a concern. Bobby was discharged home. Overnight Tommy’s condition worsened. Louisa had
gone out that night and left her son in the care of her mother who she was living with. Her mother Leanne was also a Registered Nurse. Tommy had vomited in his bed and on the floor in his room so
when Louisa returned she found Tommy in her bed. Louisa gave him Paracetamol and Promethazine to help him sleep and then continued with Panadol and Ibuprofen to help with the fever.

The next day at approximately 1200hrs, Louisa took him to the local medical centre where they saw Dr Ashfield. had a temperature of 39.7 and a respiratory rate of 39, was lethargic, dry lips, poor
capillary refill and an ear nose and throat examination revealed a strawberry tongue. Dr Ashfield diagnosed Tommy with scarlet fever and provided a letter requesting admission at the Emergency
Department of GRH.

On the 16th September at 1240 hrs
Tommy was triaged by a nurse and the following observations recorded- Axilla temperature of 38.3 degrees, pulse 67, respirations 24, oxygen saturation 88% and grunting on expiration. It was noted
that when the probe was repositioned the oxygen saturations increased to 100%. At 1245hrs, Tommy was seen by Dr Ingleburn a paediatrician in the Emergency Department who noted that there was a
history of a rash, a high respiratory rate and ‘some lung sounds’. His diagnosis was scarlet fever with a chest infection. Dr Ingleburn ordered IV Penicillin 1.2 gram four times per day and IV
fluids for maintenance and admitted him to the HDU where regular monitoring of vital signs could occur.

16th September at 1400 hrs The report was provided by Dr Dargan a radiologist at GRH on the chest x-ray from the day before indicated that pneumonia was present. The Emergency Department did not
receive this report until 2 pm on the 16th September. GRH uses electronic transfer of information such as digital x-ray imaging. Tommy’s x-ray would have been available 2-3 minutes after it was
taken to the treating medical officer. During the course of the afternoon Samuels vital signs both heart rate and breathing remained extremely high. Pulse rate 170.

At 1350 hrs the nurses documented on the observation chart that Tommy’s pulse was 191 and respiratory rate was 62. The nursing documentation also noted rib recession. The nursing care plan
indicated hourly observations to be taken.
Observations were recorded by an Enrolled Nurse Walter Hanley at 1350hrs, 1415hrs, 1420hrs, 1550hrs, 1750 hrs, 1905hrs, 2045hrs, 2155hrs, 2255hrs.
Tommy was on constant telemetry observations. His pulse rate fluctuated between 171 to 192 beats per minute.

At 1900 hrs Dr Ingleburn reviewed Tommy’s condition and noted that his vital signs were unaltered. Louisa indicated that her son was in a lot of pain. At 2245 Dr Mallee ordered analgesia for Tommy
At 0030hrs pulse rate was 151.
17th September 0045hrs
At 0045hrs on the 17th September Tommy pulled the cannula out of his arm. A senior medical officer form the ED Dr Mallee attempted to re-cannulate Tommy but was unsuccessful. Tommy vomited once
more. 1
At 0100hrs Tommy stopped breathing, no pulse and went in to full cardiopulmonary arrest At 0130 hrs defibrillation was attempted twice without success

At 0140 hrs 500 mls of brownish fluid was collected from the left lung cavity At 0200hrs efforts for resuscitation were ceased and life was pronounced extinct.
From a clinical governance and quality assurance perspective you are to write a report about a critical incident that has occurred.