Willow Kātarina Horne: All recommendations from investigation of WA baby’s death yet to be implemented

Nearly a year after the death of a baby girl at a regional WA hospital, health officials haven’t implemented all recommendations from a clinical investigation into her care. Eight-month-old Willow Katarina Horne was pronounced dead after her condition deteriorated during the two nights she spent at Kalgoorlie Health Campus. There was a chance the little girl could still be here with her parents, Kaydence Sutherland and William Horne, today had trained medical staff followed procedures to review and escalate her care. WA Country Health Service executive director for clinical excellence Helen Van Gessel on Sunday described the investigation into Willow’s care as having identified “a number of opportunities” for improvement. She said the findings included “potentially” bringing in “a fresh pair of eyes” when a patient was deteriorating, like in Willow’s case. “We made multiple recommendations aimed at improving the way we deliver care,” she said. “Those recommendations relate to additional training for staff, standardizing communication, streamlining ways to liaise with intensive care unit — particularly the tertiary paediatric intensive care unit where that’s required — and looking at continuing to improve the way we coordinate patient transfers, particularly aeromedical transport. “It is important to emphasise, however, that the panel’s view was that even with all of these improvements in place, it unfortunately may not have changed the tragic outcome for baby Willow.” However, it is also unknown whether Willow would have survived if her treatment followed the procedures to review and escalate her care. Diagnosed with pneumonia and mild dehydration on admission, results of an X-ray taken of Willow’s chest would later show her heart had more than doubled in size, but that had not been included in her clinical notes. The incident report noted that Willow’s blood tests — which showed dangerously-high lactic acid levels — did not appear to have been “formally interpreted”. When her heart began to fail, a transfer to Perth Children’s Hospital was scheduled but not given top priority, and then delayed. Two of the report’s seven recommendations yet to be completed include rolling out a colour-coded tool to automatically flag concerning blood test results and streamlining Statewide coordination of patient transport. Dr Van Gessel said while the cause of Willow’s death had not been confirmed, the panel concluded it was likely due to myocarditis — an inflammation of the heart muscle, usually related to a viral infection. Despite Willow’s deteriorating condition, the incident report revealed she wasn’t the first to be seen at the time. Dr Van Gessel said the hospital had not been any busier than usual at the time, and had its full complement of staff. “We’re really conscious of the challenges of staffing in our hospitals, but that wasn’t the case for this case,” she said. The investigation launched soon after Willow’s death last September wasn’t finalised until February, taking nearly three times longer than the usual timeline allocation of six weeks. Dr Van Gessel couldn’t explain why the report wasn’t completed within the required 45 days but said the case was reviewed by the Health Department. “Most of our reports get finished in the normal time frame. Things that are more complex, we would rather get it right than rush,” she said. The investigation noted there was “insufficient consideration of alternate diagnosis” for Willow. It also noted Willow’s racing heart, persistently rapid breathing, abnormal blood oxygen levels and an enlarged heart, “were not synthesised into a diagnostic ‘red flag’ prompting earlier diagnostic reset.” Ms Sutherland said losing her daughter had been “a nightmare” and she “always knew” there was more that could have been done to save Willow. “I knew she needed to be taken to Perth,” she said. “We couldn’t have imagined that when we took her to the hospital, she would never be coming home.”