INDEPENDENT WATCHDOG TO INVESTIGATE EMERALD TODDLER DEATH

Health Minister Stephen Robertson will refer the tragic death of Ryan Saunders to the independent health watchdog after Queensland Health completed its own internal investigation into the case.

Mr Robertson, visiting Rockhampton Hospital, said Queensland Heath’s peer review of the case had been discussed with Ryan’s parents who only agreed to its recommendations being disclosed to the media.

The Coroner confirmed that Ryan died from Group A Streptococcal Infection Toxic Shock Syndrome which is extremely rare in toddlers.

“I again want to express my deepest sympathies for the Saunders family over their loss and hope this exercise has provided them with more answers regarding this awful tragedy,” Mr Robertson said.

“Ryan’s death has now been the subject of two separate exercises – the Coroner’s autopsy report and Queensland Health’s Root Cause Analysis.

“But to ensure this case undergoes as much scrutiny as possible, I have referred it to the independent Health Quality and Complaints Commission.

“Nothing we can do can ever make up for this sad loss of life, but we can trace back to what happened and find ways that could prevent this extremely rare cause of death from being repeated.

“That is what Queensland Health’s investigation did.”

Mr Robertson said the root cause analysis, led by Mackay Hospital’s chief paediatrician Dr Michael Williams, made similar findings to the Coroner’s independent autopsy report in relation to the clinical staff involved.

The review team concluded that Ryan’s death was ‘a sad, very difficult and exceptional case’ and ‘staff involved with Ryan’s case showed concern, were diligent and were concerned about his having a serious illness’.

“However, the team made some important observations about the care that was provided at Rockhampton Hospital,” Mr Robertson said.

“They have made four recommendations which will be considered to potentially minimise such deaths from occurring again.”

The review team recommended that Queensland Health:

• Review and implement a standardised paediatric medical emergency team system throughout Queensland Health hospitals. All paediatric staff be encouraged and assisted to attend a paediatric life support course, and an observational protocol be adopted for children in hospital with potential serious illness. This protocol will include but not be limited to: airway, breathing, circulation and disability, accurate fluid balance, pain scale etc;

• Adopt a policy for Queensland Health hospitals that in screening for occult bacterial sepsis in young children the blood test include full blood count, blood culture and

c-reactive protein;

• Review rostering practices for the Intensive Care Unit at Rockhampton Hospital in conjunction with the paediatric ward to allow for the care of a child in the ICU without compromising care in the paediatric ward; and

• Ensure paediatric medical and nursing staff at all hospitals where children may be admitted be educated regularly about Septic Shock, including Toxic Shock Syndrome. This may include Royal Children’s Grand Rounds which present to regional hospitals. In conjunction with Tropical Public Health an audit of septic shock in children, including Toxic Shock Syndrome in Queensland be undertaken and published. Recognition of septic shock be put into all new paediatric staff orientation manuals.

Toxic Shock Syndrome has a high mortality rate ranging from 30 to 50 percent of cases.

In comparison, the well known disease of meningococcal infection has a mortality rate for Type B of 8 percent and Type C of 15 percent.

MEDIA: Joshua Cooney 3234 1185