March 2012

Board: Medical Board of Australia
Finding Date: 26 March 2012
Details: Inquest into the Death of Amber Sweetman by the State Coroners Court of South Australia constituted by Anthony Schapel, Deputy State Coroner.

Summary

From time to time, a state coroner may refer a finding of an inquest to AHPRA or the Board to bring to the attention of the profession. AHPRA will publish a case summary of each referral from the Coroner on its website, naming the deceased person, with the coroner’s recommendations in full. A link will also be provided to the coroner’s website. Practitioners are encouraged to access the AHPRA website at www.ahpra.gov.au to keep up to date with these cases and the coroner’s recommendations.

When the Board decides that a referral from the coroner has wide-reaching implications for practitioners, it may publish a summary of the case, and highlight particular issues relevant to the profession.

Major issue considered by the Coroner: Delay in diagnosis due to the lack of availability of CT imagery records and the reliance on such imagery over clinical presentation.

Introduction and Background

Amber Jayne Sweetman, aged 10, died at the Women's and Children's Hospital on 18 February 2009. The cause of death was congenital hydrocephalus. Amber's congenital condition was the result of a malformation of the brain that had been diagnosed and evaluated at or around the time of her birth and in early infancy. A ventriculoperitoneal shunt had been placed in her brain in order to drain excess cerebrospinal fluid that in her condition would accumulate in her skull.

On 13 February 2009 Amber was conveyed by the South Australian Ambulance Service to the Flinders Medical Centre (FMC) Emergency Department. At 7pm clinicians performed a CT scan of Amber's brain in an attempt to definitively diagnose her presentation. The CT scan reports of previous scans taken in 2004 and 2007 at the Women’s and Children’s Hospital (WCH) were accessible by clinicians but not the actual imagery. The comparison between the CT scan taken at 7pm on 13 February 2009 and the 2004/2007 reports of previous scans was not conclusive of a diagnosis of a blocked shunt.

When the imagery of the 2004/2007 CT scans became available, (approximately one hour later), and were compared to the image taken at 7pm, the CT scans collectively supported a diagnosis of a blocked shunt. The Deputy Coroner stated that had Dr D an ‘unaccredited neurosurgery registrar’ been given access to the previous imagery she “suggested, that the conclusion that there were acute changes exhibited by the 2009 imagery when compared to the 2007 imagery could have been identified instantly and that she could have performed an EVD in the Intensive Care Unit within 10 to 15 minutes of examining the imagery at about 7:13pm’.

The Deputy Coroner heard independent expert opinion including that given by Professor Reilly a neurosurgery specialist. His evidence as described by the Deputy Coroner “was to the effect that Amber Sweetman’s clinical presentation as well as the CT imagery, compared as it was to previous reports, should have been sufficient to enable the clinicians to reach a conclusion or diagnosis that Amber was suffering from significant raised intracranial pressure. In essence, the view is that any further delay in the administration of surgical intervention, either by way of EVD or revision of the shunt, was unnecessary. That opinion of Professor Reilly suggests that the EVD that was ultimately carried out was undertaken with undue delay and could have been administered earlier having regard to the information that was known about Amber at the time the CT scan images were evaluated by Dr D, and Dr F, a radiology registrar at or around 7:13pm”.

Dr A, a consultant radiologist at FMC involved in Amber’s case and a supervisor of Dr F did not share Professor Reilly’s perspective. Dr A stated “I do not think it unreasonable for a practitioner to conclude, without access to previous images, that there is insufficient change between the 22 November 2004 and 18 October 2007 reports and the 2009 CT scan to come to a conclusive view that there was shunt blockage, warranting urgent surgical intervention”.

The Deputy Coroner stated that “I do not think anyone doubts that if a confident diagnosis of a blocked shunt had been made, an EVD would have been performed without delay. The question remains whether such a confident diagnosis should have been made on the basis of Amber’s clinical presentation alone or on the basis of her presentation together with the CT imagery without recourse to previous imagery”.

The Deputy Coroner found that

1. Drs D and F were genuinely unable to achieve a sufficient level of certainty about the significance of the CT findings. I acknowledge that Professor Reilly is of the opinion that a conclusion that Amber was experiencing raised intracranial pressure from a blocked shunt could have been drawn by comparing the imagery taken that night with the available previous reports. Dr A, on the other hand, has expressed a differing view and that is that reasonable minds might differ as to how the CT scan taken that evening ought to have been interpreted. To my mind this is one of those cases where indeed reasonable minds may have differed. I am not critical of the lack of certainty experienced by Dr D and Dr F in relation to the significance of the CT scan and Dr D’s lack of certainty in relation to a diagnosis of raised intracranial pressure due to a blocked shunt. I am satisfied that in her own mind she did not have a sufficient degree of certainty that would have dictated a course of action that involved the administration of an immediate EVD.
2. The correct diagnosis was made, but only after a significant delay. The delay in diagnosis could have been avoided if by electronic means the previous CT imagery of Amber’s brain taken in 2004 and 2007 at WCH was immediately made available. There is no doubt that had it been available, a diagnosis of raised intracranial pressure due to a blocked shunt would have been made at or around 7:13pm and that relieving measures in the form of an EVD would promptly have been administered. However, it cannot be known with certainty whether Amber Sweetman’s death could have been prevented if an earlier diagnosis had been made in respect to raised intracranial pressure due to a blocked shunt.

Deputy Coroner’s Recommendations

1. That the Minister for Health cause to be expedited the digitisation of radiological imagery at the Women's and Children's Hospital;
2. That the Minister for Health cause to be expedited the implementation of the centralised digital system of storage of radiological imagery available for access by all public hospitals in South Australia;
3. That these findings be drawn to the attention of the wider medical profession, including but not limited to general practitioners, emergency clinicians and paediatric, neurological, neurosurgical and radiological trainees. I direct this to the attention of the Minister of Health, the principal administrative officers of all South Australian medical schools and the South Australian Board of the Medical Board of Australia through the Australian Health Practitioner Regulation Agency.