Crucial information not passed on to doctors before girl, 3, died from flu, inquest finds

Paramedics who drove a little girl to a Sydney hospital where she died from the flu failed to pass on crucial information that could have changed the outcome, an inquest has found.

Caitlin Cruz, 3, died amid a “paucity” of information and a series of failures by medical staff in October 2016 after she was taken by her father Mitch to a medical centre in Sydney’s west.

The girl, remembered as a child with a zest for life, had fallen ill after returning from daycare with a fever on October 18.

On October 22 she collapsed in her dad’s arms while waiting in a Rhodes medical clinic, with a GP telling the inquest into her death she was the “sickest girl” she’d ever seen.

Dr Sumeena Qidwai told the inquest that Caitlin had blue lips, was unresponsive and barely breathing and had little detectable pulse or blood pressure, details she claimed to have told paramedics called to the scene.

During the inquest one of the paramedics agreed they knew Caitlin had been unresponsive and developed blue lips but said Dr Qidwai told them on arrival that the girl had “come up well”.

The paramedic denied being told that Caitlin had no detectable heart rate otherwise they would have immediately escalated her treatment.

Deputy State Coroner Derek Lee, however, found it was most likely they had been informed of those symptoms, which were not included in ambulance medical records.

“Caitlin died of natural causes, in circumstances where a number of critical factors contributed to the tragic outcome,” Mr Lee wrote in his findings.

“These factors include the inaccurate and unreliable transfer of information from a pre-hospital setting to a hospital setting, the inability to perform an electrocardiogram in a timely manner, the absence of adequate documentation and the absence of appropriate escalation of Caitlin’s care for review.

“This in turn led to missed opportunities for further investigations to be performed, more timely recognition of Caitlin’s deterioration and specific supporting therapies being instituted to manage Caitlin’s condition that may have altered the eventual clinical course.”

Mr Lee found the worrying observations were also not passed on to the nurse who triaged Caitlin at Westmead children’s hospital that day. She died at the hospital the following morning.

Medical notes from the treating nurse stated the paramedics told her that Caitlin had seen her GP and an ambulance was called because she was “was flat, not engage talking”.

The ambulance’s medical record, which one of the paramedics claimed to have delivered to Caitlin’s bedside, was also never found.

“Regrettably, this meant that the significance of events at the medical centre was not clearly or properly understood,” Mr Lee found.

“This paucity of information in turn adversely affected Caitlin’s subsequent clinical course and management, leading to a lack of appreciation regarding the extent of her pathology.”

About 3pm on the day before she died Caitlin experienced a seizure and was taken to a resuscitation bay before becoming alert again.

Caitlin was eventually moved to a medical ward where an ECG was ordered but was not completed for about four hours as the machine was out of battery.

When it was done a junior staff member reviewed the results without the oversight of a superior.

After her death a post-mortem examination revealed the presence of influenza B, inflammation of her airways and fluid build-up in her heart and lungs.

Mr Lee recommended in his findings that systems needed to improve to ensure the accurate transfer of medical information that could save lives.

“Caitlin’s wonderful spirit, her special qualities, and the amount of life that she lived in her brief three years will endure,” Mr Lee wrote.

“As Caitlin herself was a fighter, so too have her parents selflessly fought for change and improvement that will hopefully benefit many families within our community.”