The death of an 11-month-old baby whose x-ray revealed a fracture that went unchecked by doctors has prompted changes at a major New South Wales hospital.
Warning: This article contains details that some readers may find disturbing.
The baby was admitted to Dubbo Base Hospital's emergency department in 2019 with head injuries and died days later.
A post-mortem examination revealed the infant suffered from non-accidental head trauma and other suspicious injuries.
A separate police investigation is underway to uncover how the infant sustained those injuries before arriving at the hospital.
Due to the serious nature of the case, the Western Local Health District (LHD) conducted an internal review that found the fracture was missed.
The investigation found the x-ray was "not reviewed in a timely manner" and that there was a "a gap in the electronic medical record system process".
Doctors given time to check results
The Western LHD said it had since made changes so image and test results could be followed up and communicated to the relevant health practitioners within the emergency department.
Dubbo base hospital chief executive Mark Spittal said the changes meant a senior member of staff would be rostered on to check imaging results, should the authorising doctor be unavailable.
"What we identified was that we really needed to quarantine some time for a senior doctor in the department [to review test results]," he said.
"For example, you may have a doctor who orders a test result, the result doesn't come back before the end of their shift and they may not be rostered to work for several weeks. If they're a locum they might not come back for months."
'No human system is perfect'
The staffing review also investigated complaints from three different cancer patients about their care.
Mr Spittal said in some of those cases the review found individual results had been looked at, but that the "incidental finding wasn't actively followed up on".
"No human system is perfect," he said.
"There are millions of diagnostic results that get ordered across our system every year and a couple of hundred thousand of people who go through our system.
"Nevertheless, the trust and confidence of those individuals in our system clearly gets challenged when everything hasn't gone perfectly the way that we'd hoped it would."
The health district said no further cases have been identified since the staffing changes were put in place.
