A three-year-old boy died in hospital because nurses were convinced the hospital’s monitoring equipment was faulty instead of questioning whether he was critically ill.
The nurses spent too much time on the equipment instead of manually checking whether the boy was alive, a New South Wales coroner found.
Aidan Mara died in July 2014 from Influenza A, two days after he arrived ‘very unwell’ at Sydney’s Sutherland Hospital.
The toddler’s condition fluctuated during that time and on the morning of his death he was more alert and ‘interested in eating and drinking’.
But things got worse when a decision was made to shower a soiled Aidan after his catheter was removed.
Aidan Mara (pictured) would have celebrated his seventh birthday on Monday if he was still alive today
Two nurses – one of whom had worked at the hospital for more than 20 years – decided to take out his oxygen nasal prongs ‘without any great thought’ or consultation with the medical team.
Deputy State Coroner Teresa O’Sullivan said it was ‘understandable’ that a quick decision was made to disconnect him given he was distressed.
‘It is clear, however, that the decision to do so was an error,’ she said in her findings on Friday.
‘I am not satisfied that any close attention was paid.’
At the end of the shower, Aidan collapsed and was returned to bed.
The nurses reattached the oxygen and monitoring sensors but were unable to get adequate readings. They spent some time checking the machine thinking it was faulty.
Lucas Mara described his son Aidan (pictured) at the inquest as a clever and vibrant child whose smile and loving personality were his most endearing features
Aidan appeared to fall asleep a short time later but the boy’s grandmother noticed he was not breathing and his lips and chest were cold.
Ms O’Sullivan concluded the ‘nurses fell into error in focusing too long on the monitoring equipment without checking the physical signs of whether Aidan was breathing’.
‘There is sufficient evidence that the time between Aidan collapsing and the time of calling for medical review was unacceptably long, as a result of the fixation on the monitoring equipment, which the nurses thought must be the cause of the failure to get adequate readings,’ she said.
‘The nurses were convinced that the monitoring equipment was faulty rather than questioning whether Aidan was critically ill and using basic manual checks.’
Both nurses admitted to the inquest they made errors. Neither recalled having received training about how to avoid ‘fixation errors’.
Lucas Mara (pictured) recently took part in a fundraising bike ride from Sydney to Canberra in son Aidan’s honour
Ms O’Sullivan was particularly touched by words from the statement Lucas Mara made on behalf of his family.
Lucas Mara described his son as a clever and vibrant child whose smile and loving personality were his most endearing features.
‘In many ways we see it as our responsibility to ensure Aidan’s loss was not in vain. We hope that there are lessons to be learned not just about avoiding tragedies in the future but also about love in general and the importance of humanity and the sense of community,’ Mr Mara told the inquest.
The deputy coroner recommended to South Eastern Sydney Local Health District that a component of the training for nursing staff to address the phenomenon of ‘fixation errors’.
She noted hospital staff were ‘deeply saddened’ by Aidan’s death and acknowledged that the health district had proactively made a number of changes as a result.
Aidan Mara’s parents regret not getting their son (pictured) vaccinated against the flu
‘As a result of Aidan’s tragic death, the South Eastern Sydney Local Health District appears to have been proactive in determining what lessons could be learnt in order to identify system improvement opportunities, so as to minimise the risk of a similar death in the future,’ Ms Sullivan said.
‘I am satisfied that there is now training in place.’
She also commended the ‘extremely gracious’ conduct of Aidan’s parents throughout the inquest to the hospital staff and the court.
‘It was in that spirit that the family conducted themselves in this inquest, and I hope that they can take some comfort from the evidence that lessons do indeed appear to have been learnt,’ Ms Sullivan said.
Following the inquest, Mr Mara accepted the errors weren’t deliberate but hopes the inquest will drive change.
Aidan Mara died two days after arriving at Sutherland Hospital (pictured) in July 2014
Aidan would have turned seven on Monday if he was still alive today
‘It wasn’t done through any malice, but to make change we need to be aware of things that have gone wrong, and put our hands up when things do go wrong,’ Mr Mara told reporters outside Glebe Coroners Court.
‘It has helped a lot, calling out what we believe went wrong at the time.’
Mr Mara wished he knew young kids could be vaccinated against for the flu.
‘Whether you choose to be pro-vaccine or anti-vaccine at least know there is a decision that you can make,’ he said.
‘Regrettably if we had have known we probably would have got the vaccine for Aidan.’