EXCLUSIVE: THEY WERE NEVER TOLD THE FULL STORY..! – A confidential report has revealed a series of missed medical warning signs and critical transport delays before the tragic d-e:ad of an eight-month-old baby at a WA hospital—findings the grieving parents say were kept from them.
At just eight and a half months old Willow Kātarina Horne was a beautiful, happy and deeply loved baby girl taken from her adoring mum and dad in the most cruel way.
It was after 8.30am on a Tuesday late last year when, after nearly an hour of resuscitation, she was pronounced dead at a regional WA hospital — shattering the lives of her parents, Kaydence Sutherland and William Horne, in an instant.
What makes her death so hard to comprehend for the couple is that there was a chance she could still be here with them today, had trained medical staff followed procedures to review and escalate her care.
“I just always knew that there was more that could have been done to save Willow and I knew she needed to be taken to Perth,” Miss Sutherland said.
“We couldn’t have imagined that when we took her to the hospital, she would never be coming home. This has been a nightmare and I think about Willow every single day.”
Details of Willow’s treatment have surfaced in a clinical incident investigation report which had been kept secret from Willow’s parents.
Willow Katarina Horne was just eight-and-a-half-months-old when she died at Kalgoorlie Regional Hospital. NO
It was only handed over after senior doctors contacted The West Australian with concerns.
The West does not suggest any doctors or medical staff at the regional hospital are guilty of any medical negligence or malpractice only that the incident investigation report about Willow’s treatment has been completed.
Willow was admitted to the hospital at about 12.30am on a Sunday with shortness of breath and decreased appetite.
Her heart rate was slightly elevated, and her respiratory rate was within normal range.
An assessment found no signs of congestion in her chest or wheezing.
A chest X-ray was taken which reported inflammation, or fluid, in the tissue supporting the air sacs across both of her lungs.
Willow was given a diagnosis of pneumonia with mild dehydration and placed on saline drip with antibiotics to treat the suspected infection.
At 6.15am Willow was admitted to the ward — where it was noted that her respiratory rate had increased.
By 12am on Monday, Willow was vomiting, and her breathing difficulties had increased.
Another chest x-ray was taken.
The results would later show that Willow’s heart had more than doubled in size — but this was never noted in her clinical notes.
At 2am a nurse raised concern after Willow’s respiratory rate had more than doubled.
They phoned a doctor and updated them on the situation but no change was made after a review of the latest X-ray.
Willow Katarina Horne with parents Kaydence Sutherland and William Horne. NO
The investigation report said in retrospect calling a medical emergency at that time would have resulted in a more experienced doctor attending and may have prompted a different diagnosis. It may not have influenced the outcome.
Willow’s breathing continued to worsen over the following hours, nurses did document their concerns but did not call a medical emergency because the doctors were aware of the situation.
At 6.40am a nurse requested an urgent medical review — concerned about Willow’s condition.
She was reviewed by a doctor who did not make any changes to her treatment.
The investigation report noted that Willow’s blood tests taken nearly five hours earlier which showed dangerously high lactic acid levels, did not appear to have been “formally interpreted.”
It’s a common sign of serious underlying issues like organ failure, or severe infection.
“This interpretation may have been contributed to by inexperience of the doctor on site, and the senior doctor being offsite with communication via phone, leading to an overall impression that the gases were reassuring,” the report stated.
Willow Katarina Horne. NO
The investigation noted that had proper processes been in place to formally interpret the blood test results, it would have triggered an amber warning and required the intervention of a more senior clinician.
Willow was assessed again at 10.20am by a doctor — who did not reconsider her diagnosis.
“It is not clear why the diagnosis of pneumonia was made considering the relatively clear lung fields on examination and chest x-ray,” the report stated.
“A more comprehensive reconsideration of diagnosis and management should have occurred at this time, and that this was a missed opportunity for earlier reconsideration of the diagnosis.”
Despite Willow’s deteriorating condition — she wasn’t the first to be seen on the ward round by the doctor.
There was also no hand-over between doctors during shift change to relay her condition.
Another set of blood tests were taken around 1pm and reviewed an hour later by two doctors who did not record having formally interpret the results.
They later showed the lactic acid in her blood was continuing to rise.
By 4pm on Monday — some 40 hours after Willow was first admitted — another nurse requested a medical review of Willow over concerns for her deteriorating condition.
A doctor attended and an ECG was performed which found she had abnormal flow, a fast heart rate, and showed signs that her heart was under strain.
It was at this point that doctors began to consider a different diagnosis to pneumonia but, by then, Willow’s heart was already beginning to fail.
Her X-ray and blood results were sent to Perth Children’s Hospital where the cardiology team agreed she needed to be airlifted for specialist treatment.
Kaydence Sutherland and William Horne are grieving the loss of their eight-month-old daughter, Willow Kātarina Horne. Yes
The investigation panel noted that doctors at the regional hospital didn’t communicate the seriousness of Willow’s condition to the transport coordination centre and she wasn’t given the highest priority level of 1.
It took three hours before she was accepted for air transfer. She was then scheduled to be collected from the regional hospital in another six hours at 1am.
But, at just after 11 o’clock the plane was diverted to collect a priority 1 patient — no new estimated arrival time was given.
Willow continued to deteriorate – and the investigating panel found that there were several occasions where medical emergencies should have been declared – which would have resulted in more experienced doctors attending.
Nursing staff were trusting the doctors who were aware of the situation and decided not to escalate Willow’s case.
At 3.30am on Tuesday — Willow was still waiting for a transfer flight — where she could have been taken to PCH and put on Extracorporeal Membrane Oxygenation therapy, a life support intervention which would have taken over from her failing heart.
Within an hour — staff began performing resuscitation on Willow as she declined further.
It wasn’t until 7.15am on Tuesday that the hospital contacted the air transfer service to have her upgraded to a priority 1 patient.
At 8.41am Willow went into cardiac arrest — 57 minutes later — she was dead.
The investigation noted there was “insufficient consideration” of alternate diagnosis for Willow.
It also noted that 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.”
Health Minister Meredith Hammat. YES
“Repeated Early Warning Score (of) greater than 6, red-zone respiratory rates, and lactate elevation did not result in (a) Medical Emergency Review activation or critical care consultation as required.”
Staff did not consistently trigger the mandatory escalation pathways required in Willow’s case, which the report noted was not consistent with policy and procedure.
There was limited “situational awareness” shared between the regional hospital, PCH and the aeromedical transfers team as to how critical and urgent critical Willow’s transfer was.
The short staffing of the aeromedical team, was also labelled “the most clinically significant constraint” in the lead up to her death.
Shadow health minister Libby Mettam has viewed the damning report into Willow’s care and says the little girl and her heart broken family were completely failed by the health system.
“This account of the tragedy surrounding the death of Willow deserves a comprehensive investigation by the coroner, and I urge the Cook Labor Government to initiate this — it is the right thing to do,” Mrs Mettam said.
“Given the obvious challenges of a regional setting and a number of red flags that were there, it is essential we see a thorough and transparent Inquest into baby Willow’s death.
Kaydence Sutherland and William Horne are grieving the loss of their eight-month-old daughter, Willow Kātarina Horne. Yes
“Our heart goes out to Willow’s family who deserve answers.”
Health Minister Meredith Hammat won’t request that the Attorney General order a coronial inquest into Willow’s death but said she “absolutely support” the coroner in holding one.
“I’m deeply sorry to Kaydence and William on the unimaginable loss of Willow,” Ms Hammat said.
“Willow’s death was subject to a detailed clinical review, with the panel of clinical experts making seven recommendations aimed at improving systems.
“WA Country Health Service has advised all of these recommendations are progressing and I expect that every recommendation is implemented in full.”
Ms Hammat said it was her “expectation” that the clinical investigation report into Willow’s death should have been handed over to her parents.
“If Kaydence and William wish to meet with me, I will of course make myself available,” she said.
WA Country Health Service claims it did offer to provide the investigation report to Willow’s family.
