Six doctors in four days: A new system aimed at escalating care for very ill patients has been implemented, after a little boy unnecessarily and tragically died when multiple doctors failed to spot a fatal infection.
Tragic, preventable death
Six doctors saw two-year-old Lachlan Black over a period of four days, but despite his parents’ exhaustive efforts, nobody commenced the lifesaving antibiotic treatment that would have saved his life until it was too late.
Many, many opportunities to treat the little boy in a timely and appropriate manner were missed. Lachlan died of septicaemia (also known as sepsis) in August 2014, after doctors at Melbourne’s Monash Medical Centre diagnosed him with a viral infection, despite his parents’ concerns that it was something more serious.
Septicaemia is a blood infection caused by bacteria and can be fatal if not treated quickly. Symptoms of septicaemia may include: Fever with chills, inability to walk, nausea, vomiting or diarrhoea, abdominal pain, confusion, shortness of breath, rapid heart rate.
“We kept being told ‘it’s just a virus’ and ‘keep doing what you are doing’ by doctors,” Lachlan’s mother, Angela Black explained, The Age reports.
By this time, Lachlan had deteriorated to the point where he could no longer walk and had an elevated heart rate. Angela and her husband Tim knew their child was gravely ill, but still doctors overlooked the seriousness of Lachlan’s symptoms.
“Just a virus”
In the days before he died, Lachlan had been taken to two different GPs, the emergency department twice and then again – a third time on August 17 in 2014 – to the emergency department of Monash Health’s Clayton emergency department. This was his final visit. Doctors then took over nine hours to administer the antibiotics that could have saved his life.
In the early hours of August 18, following 30 minutes of CPR in an attempt to revive the little boy, Lachlan died.
Lachlan’s death has just been investigated and a teary Coroner Rosemary Carlin determined that the little boy received poor care, with tragic results. She also noted that emergency rooms were high-pressure environments where staff were often doing their best under challenging circumstances.
“In my view, the shortfalls in Lachlan’s medical management constituted a departure from a reasonable standard of care. They appear to have been caused by a combination of human errors and failures of the system to prevent or counteract human errors.”
She said an initial misdiagnosis led to a series of biased decisions involving Lachlan’s treatment.
“Even when it was appreciated that Lachlan may be suffering from a bacterial infection and antibiotics were ordered, there was a two-hour delay. Lachlan’s tragic death highlights the need of medical practitioners to be ever vigilant,” the Coroner said, the ABC reports.
New escalation process
As a result of Lachlan’s death – and further concerns raised about parent’s worries being routinely overlooked – a new system has been implemented to avoid terrible mistakes and misdiagnoses like this.
The Coroner also ruled that Monash Health should “develop a formal policy requiring patients who present twice within 72 hours to have their diagnosis re-evaluated by an emergency department consultant as soon as possible,” The Age reports.
Victorian Minister for Health Jill Hennessy pledged to ensure the system does not fail families like the Blacks again. Monash Health have issued an apology to the family.
Listen to parents
Lachlan’s grieving parents say health professionals need to take parents’ concerns seriously, when it comes to the health of their kids, because the consequences of NOT listening can be devastating.
“Really we are the best barometer of how our child is in terms of their health,” Angela Black said.
“Doctors need to keep in mind that their profession, when they make mistakes and if they make mistakes, those mistakes can’t be undone,” Lachlan’s dad Tim Black said.
“While we will never get our son back, we can hopefully prevent other parents from having to go through the hellish journey we’ve gone through.”
The Coroner agreed that parents often felt ignored, and this had to change.
“Whether based on truth or perception, such a complaint is common. Family members are a vital source of information for a patient’s health.”
The various Australian states and territories have other escalation processes to ensure parents are listened to and children get the care they need.
In Queensland, call 13 Health (13 432 584). Ask to invoke Ryan’s Rule and request a Ryan’s Rule clinical review – you’ll need to provide your child’s name, the hospital name, your child’s ward and bed number and your contact details.
New South Wales has the REACH communication process (Recognise, Engage, Act, Call, Help is on its way). Ask medical staff how you can access REACH, or visit the Clinical Excellence Commission.
Canberra Hospital has the Call And Respond Early program (CARE) to help facilitate communication and assess treatment escalation.
For parents in other states and territories, your hospital’s Patient Liaison Officer can advise on the escalation process.