Hospital failures before toddler's death, coroner finds

A 19-month-old toddler died from a bowel obstruction after hospital delays in diagnosis and transfer, and failure to undertake required regular observations, a coroner has found.

The girl was "gravely unwell" when she arrived with her mother at Launceston General Hospital in Tasmania in the early hours of June 10, 2021.

She was triaged as a category two, to be seen within 10 minutes.

Her assessment as 'level six' under an early warning tool required the hospital to follow several procedures, including conducting a senior doctor review within 15 minutes and completing observations at least every 15 minutes.

"(Her) medical records suggest that none of this was done," coroner Simon Cooper wrote in findings published on Monday.

Her first recorded clinical observation was at 2.20am. She was first reviewed by a doctor at 4.21am, according to medical records.

At 4.45am she was reviewed by a paediatric registrar, with records indicating a small bowel obstruction was suspected.

Medical imaging was requested at 6am but was not carried out for another hour or so.

Clinical observations were recorded at 7.50am, more than five hours after they were previously recorded.

Subsequent blood tests showed she was suffering acute renal failure. Her imaging was reviewed, with a decision made for an urgent transfer by ambulance some 200km to the Royal Hobart Hospital.

She arrived at 1.46pm in shock with multi-organ failure and died later that day.

"Delays associated with an accurate diagnosis of bowel obstruction meant in turn (her) necessary transfer to the Royal Hobart Hospital was delayed," Mr Cooper said.

"The failure to make that diagnosis was the result of a failure to adhere to any of the procedures mandated as a result of the score returned by the completion of the (early warning tool).

"The failure to transfer (her) to the Royal Hobart Hospital earlier may have been the difference between her survival and death."

The girl had a significant medical history after being diagnosed with a large cancerous kidney tumour requiring surgery and chemotherapy.

"But she was progressing well until June, 2021," Mr Cooper said.

She suffered pain, lethargy and vomiting before being initially taken to hospital by her mother.

Mr Cooper said the Launceston General Hospital acknowledged her death was a terrible tragedy and extended condolences to her family.

He said the hospital had undertaken a review of her treatment to "identify system improvements and learning opportunities to prevent an event of this type occurring in the future".