THE coroner is expected to hold an inquest into the death of a boy whose illness was misdiagnosed and not treated properly by medical staff at Mount Isa Hospital.
Kesler Lee James, 5, passed away at the hospital on February 25, 2012 after suffering from a respiratory disease.
His single mother, Jennifer James, had been living in a run-down public housing unit with Kesler and her four other children in Miles St, Mount Isa for about 18 months.
She believed her son’s illness was caused by bacteria originating from a poorly serviced evaporative airconditioner at the premises.
Former Public Housing Minister Dr Bruce Flegg, in mid-2012, later confirmed low levels of legionella bacteria, which can cause the potentially lethal Legionnaire’s disease, were found in the unit following departmental water testing. In a report of her draft findings, Coroner Jane Bentley found Kesler died from acute bronchopneumonia (inflammation of the lungs) and diffuse alveolar damage (lung disease) due to acute rheumatic carditis (rheumatic fever affecting the heart).
An autopsy found no trace of bacteria, including legionella, in Kesler’s lungs, but it was noted he had been given antibiotics prior to his death.
The coroner’s investigation involved two independent doctors’ reviews into the appropriateness of Kesler’s treatment and management at Townsville and Mount Isa hospitals, and a separate investigation from Queensland Health.
Ms Bentley concluded from Kesler’s final admission to Mount Isa Hospital until his death a day later, medical staff at the hospital “failed to correctly diagnose the boy’s illness and severity of it”. “Had the severity of Kesler’s illness been recognised in a timely manner, he may have been transferred to Brisbane and it is possible that his death could have been averted,’’ she said.
Ms James had initially taken her son, who had a fever, coughing, knee joint pain and breathing difficulties, to the hospital on January 29.
Kesler stayed in hospital until February 1.
After he was discharged, he developed symptoms of acute rheumatic fever, and was twice flown to Townsville Hospital for emergency treatment.
He died in Mount Isa hospital on February 25.
Dr Kevin McCaffery concluded Kesler’s life may have been saved if the seriousness of his illness had been recognised and appropriate measures taken. But he also recognised that “Kesler had a serious disease and it is quite possible that even had he received optimum treatment, he may not have survived,’’ he wrote.
“Also, his geographical remoteness would have delayed time to definitive care even in a perfect system.’’
Dr McCaffery found that although there was a failure to diagnose the severity of Kesler’s illness which led to inappropriate treatment, there was no malice, negligence or individual incompetence involved in the decision making.
“Rather there were a number of systems failures in relation to retrieval co-ordination and obtaining specialist opinions for remote patients,’’ he stated.
Forensic medical officer Dr Leslie Griffiths, wrote Kesler’s treatment in Townsville was “appropriate and in accordance with guidelines for the diagnosis and management of acute rheumatic fever.”
But he said there appeared to be “a systemic failure on the behalf of the Townsville Hospital to clearly communicate to Mount Isa Hospital what management was intended post-discharge”. He also said it was possible Kesler may have had a legionella infection when first admitted to Mount Isa Hospital, but it was not specifically tested for.
“There was no evidence of it at autopsy but by this time, Kesler had been given a class of antibiotics effective against legionella,’’ he said.
He concluded Kesler’s death was caused by rheumatic heart disease, rather than legionella.
An inquest date has yet to be set.