An Indigenous baby who was taken to hospital three times in four days before dying of pneumonia may have survived if she had been treated at hospital, a coronial inquest has heard.
The 36-day-old girl, Masaly Mosby, was found unresponsive by her mother in their home in the Kennedy Hill or Mallingbarr Aboriginal community, a collection of houses in the centre of Broome, Western Australia, at 7.30am on 6 October 2011. She was taken to Broome hospital in cardiac arrest and was pronounced dead at 9.10am.
It was her fourth time in the hospital’s emergency department in five days.
The case echoes the failure to correctly diagnose Yamatji woman Ms Dhu, who died in custody in 2014. Dhu was seen by doctors and declared medically fit to be held in custody on two occasions in the 45 hours before her death.
Fleur Allen, the counsel assisting coroner Sarah Linton, said none of Mosby’s hospital visits prior to her death led to her being diagnosed with and treated for pneumonia. “If she had been admitted on the second or third occasion, the outcome would have been positively influenced,” she said.
On the first visit, on 2 August, Mosby’s mother and aunt presented her to hospital after she had been feverish and vomiting. Allen, in an opening address to the inquest in Broome on Monday, said the group arrived at hospital at 6.15pm and were seen by a nurse and a doctor, who diagnosed Mosby with a head cold and discharged her with “instructions to give Panadol regularly.”
Mosby returned in the care of her aunt two days later. “Baby Masaly had not improved and had developed a cough, abnormal breathing and was seen to have nasal flaring and a funny cry,” Allen said. “On this occasion the baby was not seen by a medical practitioner and was taken from the [emergency department] after waiting for 20 minutes without speaking to nursing staff.”
She returned again the following afternoon, on 5 October, presenting with a cough and fevers, and was triaged as a category three, used for symptoms that are “potentially life threatening”.
Patients in that category are required to be seen by a doctor within thirty minutes, but according to Allen, Mosby was “discharged against advice” at 4.40pm, almost two hours after arriving at hospital. She had been examined by “nursing staff and a sixth year medical student”.
When her mother woke the next morning, Mosby was unresponsive.
Allen said the two-day inquest, which concludes on Tuesday, would examine the adequacy of medical care given to Mosby.
It also heard evidence from paediatrician Dr Paul Porter, who reviewed the case. In his initial report, he said Mosby should have been admitted for treatment of suspected respiratory disease from her second presentation at hospital, and criticised doctors for a lack of follow-up.
“One of the fundamental questions posed by this inquest is whether baby Masaly’s death was preventable,” Allen said.
