Inquest hears ‘what ifs’ around Jasmyn Carter's death
THE doctor who saw Jasmyn Carter when she presented at Warwick Hospital and ultimately the last doctor to see her before she died told an inquest into the teenager's death that he didn't know if he would treat the case differently if she presented in a similar condition to him today.
However, in hindsight, Dr Andrew Hughes said he should have seen that nurse observations of Jasmyn, including checks of blood pressure, pulse and temperature, had been done more frequently.
Because of a busy shift and having to do an emergency review of another patient at the time, he had not specified the frequency of observations on Jasmyn's medical chart, he said.
The hospital's senior medical officer said apart from low blood pressure and complaining of soreness in her limbs, Jasmyn did not appear to be unwell when she arrived at emergency on the afternoon of August 3, last year.
She had played a game of AFL the evening before and told him she had had flu-like symptoms for the previous four weeks, he said.
She had no respiratory distress and her blood test results appeared normal and though she complained of a mild headache there had been nothing to flag concern, he said.
Due to the low blood pressure, he prescribed fluids but by 6pm he had ordered her into a ward for continued observation.
A nurse phoned him at home at 8.15pm saying Jasmyn's blood pressure was 77 over 41.
However, Dr Hughes said Jasmyn was reportedly engaged in texting on her phone and not appearing to be otherwise unwell. At the time he believed they were dealing with a viral infection that more fluids would fix.
When a nurse called him again later that night explaining the teenager was having breathing difficulties and that purple rash had appeared, he realised what they were dealing with.
The rash was typical of meningococcal.
When he arrived at the emergency department Jasmyn was still conscious and he had been joined by another hospital doctor as well as nursing staff.
Asked by counsel assisting the coroner Megan Jarvis was the situation recoverable at that stage, Dr Hughes said, "I suspect the answer is 'no'."
When Jasmyn went into respiratory arrest, medical staff applied advanced life support measures.
"At that point I don't think anyone could have brought Jasmyn back," Dr Hughes said.
Jasmyn was pronounced dead at 3.27am.
In hindsight, Jasmyn's low blood pressure earlier was "a critical point not given as much credence as it should have," Dr Hughes said.
At the time he thought low blood pressure at 17 might not have been a serious problem but in hindsight it appeared a significant drop from her normal blood pressure.
Since then the hospital had implemented a lot of changes including improved staffing, a doctor at the hospital 24 hours a day, and sepsis awareness training.
Coroner John Lock will assess the evidence taken at this week's inquest into the deaths of Jasmyn and 86-year-old Verris Dawn Wright at Oakey Hospital on Boxing Day 2013 and deliver his findings and recommendations at a date to be set.