Inquest into the death of Finlay Browne

Case Number: 2018/17393

Findings Date: 10 May 2024

Magistrate: Erin Kennedy

CORONIAL LAW | mid-gut volvulus and bowel obstruction; ischaemic bowel; unconscious bias; consideration of disability and treatment in hospital; Bathurst Base Hospital; adequacy of care; NETS; provision of care to children in rural NSW

Responses

Recommendations to	Response
Western NSW Local Health District	Received
Sydney Children's Hospital Network	Received

Recommendations

Western NSW Local Health District (WNSWLHD)

1a. That the WNSWLHD consider the provisions of formal training to clinical staff on unconscious bias and how it influences clinical judgment, including as to persons with disabilities.

1b. Related to (1)(a) above, that the WNSWLHD consider the potential utility of Exhibit 3: the Australian and New Zealand College of Anaesthetists & Faculty of Pain Management – Unconscious bias toolkit for the purposes of such training, and consider preparing a similar ‘toolkit’ for use by clinicians within the Local Health District.

1c. That the WNSWLHD liaise with the Ministry of Health as to the review and revision process relating to the Policy Directive PD2017_001 Responding to Needs of People with Disability during Hospitalisation (January 2017) in relation to cognitive bias (noting the issues highlighted in these coronial proceedings).

1d. That as a matter of priority, the General Manager of Bathurst Base Hospital formalise a clear escalation pathway for on-call executive hospital support in circumstances of a major clinical incident within that hospital (including where there are two urgent, competing surgical cases after hours).

Western NSW Local Health District (WNSWLHD) and Sydney Children's Hospital Network (SCHN) on behalf of the NSW Newborn & Paediatric Emergency Transport Service (NETS)

2a. That the WNSWLHD collaborate with SCHN and NETS to ensure there is appropriate training for emergency department clinicians on an ongoing basis (given transient staffing arrangements), regarding:

i. Policy Directive PD2023_019 NSW Paediatric Clinical Care and Inter-hospital Transfer Arrangements (August 2023);

ii. The general availability of NETS to provide expert clinical advice and medical assistance for:

1. very sick or injured babies, children and adolescents up to the age of 16 years; or

2. patients aged 16 to 18 years with chronic or complex conditions who have not completed transition to adult health services;

iii. The benefits of early contact with NETS in relation to very sick babies, children or adolescents.

Sydney Children's Hospital Network (SCHN)

3a. That there be liaison with the Ministry of Health as to the following matters being issues that deleterious on the provision of critical care services in children in New South Wales:

i. Arrangements to ensure that NETS have priority access to a helicopter and fixed-wing aircraft; and

ii. NETS to be resourced to provide sufficient teams to address the need of the child population noting that presently, five NETS teams rotate over a 24 hour period, compared to the previously instructed rotation of six NETS teams in a 24 hour period.