The death of a six-week-old baby in a major hospital was “potentially preventable”, but a coroner could not say with certainty whether his death was preventable.
The “brave but very sick” Logan Scott Fergusson was born with serious heart defects at Adelaide Women’s and Children’s Hospital (AWCH) on April 29 2016.
Just four day later, he was flown to Royal Children’s Hospital in Melbourne (RCHM) for urgent cardiac surgery, returning to the Adelaide hospital he was born in a month later before being discharged on June 3.
The young baby would return to AWCH on June 14 after complications, and despite his oxygen levels sitting between 65-73 per cent, an echocardiogram – which measures how blood pumps through the heart – was not ordered until the next morning.
While monitoring Logan’s oxygen levels overnight, they set an accepted saturation level of 65 per cent. A healthy person should have an oxygen saturation level of at least 95 per cent.
There were 18 recordings taken throughout the night, 13 fell below the 65 per cent threshold and one reached a low of 40 per cent.
When Logan was taken for his echocardiogram, it revealed a narrowing of his left pulmonary artery requiring further surgery.
However, it was too late for the boy, who deteriorated and stopped breathing soon after 11am that day.
His death was found to be caused by hypoxia and reduced pulmonary perfusion complicating congenital heart disease.
Handing down his findings, Deputy State Coroner Ian White found Logan’s death was “potentially preventable” but could not say that it was preventable “with certainty”.
Mr White found that it was “preferable” for Logan to have received an echocardiogram when he presented to the emergency department.
“I find it was likely that an echocardiogram would have likely identified the narrowing of the left pulmonary artery if it was performed earlier,” he said.
Despite this, the coroner could not say with certainty that Logan would have been able to be stabilised for the transfer from Adelaide and to Melbourne, there was no certainty the surgery would have been successful.
“Certainly Logan was a very sick little boy. If more was done earlier in terms of elevation of care through empirical therapies, then he had a better chance of being adequately stabilised for a retransfer to RCHM,” he said.
He made no recommendations.