The death of a six-week-old baby in a major hospital was “potentially avoidable,” but a coroner couldn’t say for sure if his death was avoidable.
“Brave but very ill” Logan Scott Fergusson was born on April 29, 2016 at Adelaide Women’s and Children’s Hospital (AWCH) with serious heart problems.
Just four days later he was flown to Melbourne’s Royal Children’s Hospital (RCHM) for urgent heart surgery and returned a month later to the Adelaide Hospital where he was born before being discharged on June 3.
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The little baby would return to AWCH on June 14 after complications, and although his oxygen level was between 65 and 73 per cent, an echocardiogram – which measures how blood is pumping through the heart – was not ordered until the following morning.
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After complications from the operation, the baby was immediately taken back to the hospital
While monitoring Logan’s oxygen levels overnight, they set an acceptable saturation level of 65 percent. A healthy person should have an oxygen saturation of at least 95 percent.
Eighteen shots were taken during the night, 13 fell below the 65 percent threshold and one hit the low of 40 percent.
When Logan was taken for an echocardiogram, his left pulmonary artery was narrowed, requiring further surgery.
However, it was too late for the boy, his condition worsened and he stopped breathing just after 11 a.m. that day.
His death was found to be due to hypoxia and reduced pulmonary blood flow, complicating a congenital heart disease.
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“Certainly Logan was a very sick little boy”
Assistant Medical Examiner Ian White, in sharing his findings, noted that Logan’s death was “potentially avoidable” but couldn’t say it was “certainly” avoidable.
Mr White concluded that it would be “better” for Logan if he had had an echocardiogram when he presented to the ER.
“I think it’s likely that an echocardiogram would probably have detected left pulmonary artery narrowing if it had been done earlier,” he said.
Still, the coroner could not say with certainty that Logan could have been stabilized for the transfer from Adelaide to Melbourne and there was no certainty the operation would have been successful.
“Certainly Logan was a very sick little boy. If more were done sooner to improve care through empiric therapies, then he would have a better chance of stabilizing sufficiently to be transferred back to the RCHM,” he said.
He made no recommendations.