Inquest into the death of Caitlin Cruz

Case Number: 2016/316614

Date of Findings: 9 November 2021

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – cause and manner of death, information transfer from a pre-hospital setting to hospital setting, referral letter to hospital, senior clinician review, pericarditis, patient handover, triage, Ambulance Electronic Medical Record, documentation, neurological observations, consultant review, delay in performance of electrocardiogram, Wireless Acquisition Module battery, interpretation of electrocardiogram, Influenza B viral infection, The Children’s Hospital at Westmead, Health Care Complaints Commission 

Responses

Recommendations

To the Chief Executive Officer, Royal Australian College of General Practitioners (RACGP):

1. I recommend that a copy of the findings in the Inquest into the death of Caitlin Cruz be provided to the RACGP, inviting the RACGP to consider providing a reminder to general practitioners, in circumstances where a patient is transferred by ambulance directly from a general practice/medical centre to hospital, of the need:
   (a) to identify the hospital where the patient is to be transferred;
   (b) for a referral letter to be sent to that hospital expeditiously; and
   (c) to communicate with the receiving hospital via phone expeditiously. 

To the Chief Executive Officer, Royal Australian College of General Practitioners; Chief Executive, NSW Ambulance & Secretary, NSW Health:

1. I recommend that a copy of the findings in the Inquest into the death of Caitlin Cruz be provided to the RACGP, NSW Ambulance and NSW Health to inform consideration of whether the feasibility of a consolidated electronic platform to
   (a) facilitate the accurate and timely transfer of clinical information; and
   (b) enhance patient safety during clinical handover;
   from a pre-hospital setting to a hospital setting, ought to be explored by these organisations in collaboration.

To the Health Care Complaints Commission (HCCC):

1. I recommend that the evidence of Nurse Unit Manager Celeste Daniels and a copy of the findings in the Inquest into the death of Caitlin Cruz be forwarded to the HCCC for further consideration regarding the adequacy of the explanation provided to the HCCC in relation to the inability to perform an ECG in the emergency department on 22 October 2016, and for any further action considered necessary by the HCCC.
2. I recommend that a copy of the findings in the Inquest into the death of Caitlin Cruz be provided to the HCCC so that further consideration may be given regarding the extent to which the Sydney Children’s Hospitals Network has demonstrated compliance with recommendations made by the HCCC in its correspondence of September 2018.

To the Chief Executive, The Sydney Children’s Hospitals Network:

1. I recommend that the Sydney Children’s Hospitals Network continue to engage with the Clinical Excellence Commission to consider any necessary steps to improve documentation of clinical reasoning, and appropriate methods by which to audit compliance of such documentation.