Aboriginal and Torres Strait Islander peoples are advised that this report contains the name of a deceased person and refers to the death of a six-year-old Torres Strait Islander boy from Bamaga, Queensland. With permission from the family, this report refers to him by his name, as does this description below.

This report presents the findings of an investigation into the safety and quality of health services at Bamaga Hospital, Queensland, following the death of Charles (Charlie) Izaak Wilfred Gowa. Charlie passed away on 14 January 2017, as a result of overwhelming sepsis caused by a rare bacterial infection called melioidosis, having been initially treated at the Bamaga Hospital. This report has been made public because system improvements are needed in relation to the provision of health services in a remote environment.

Key Findings/Recommendations:

  • Charlie’s condition was not appropriately considered, deterioration was not recognised, and his clinical care was not escalated accordingly. The treatment provided during earlier presentations was likely inadequate and the failure to document any assessment on a febrile child brought in by concerned parents was not appropriate. This failure to document in medical records observations including symptoms and parental concern during earlier undocumented presentations meant that the practitioners that treated and discharged Charlie on 9 January, and ultimately admitted him on 10 January, did not have a complete picture of his condition.
  • Ultimately, this investigation does not find that the death of Charlie was preventable or that the actions of any individuals contributed to the tragic outcome. However, the systemic issues and necessary improvements discussed in this report do not rely on such a finding.
  • Providing health services in Bamaga is challenging and not unlike other very remote areas that experience workforce shortages and difficulty obtaining the right skill mix. The remoteness of the service also poses its own resourcing and support structure challenges. There is also the added pressure of delivering culturally safe services to a culturally diverse population and meeting their health needs.
  • Bamaga Hospital is required to maintain and utilise mechanisms for recognising and responding to patient deterioration. The correct use of these tools is particularly important in remote settings like Bamaga, where the evacuation of a deteriorating patient to a suitably resourced facility takes time. In relation to Charlie’s care, this investigation identified multiple instances of noncompliance with standard clinical tools, manuals and local policies and procedures designed to support clinicians in the recognition of, and response to, a deteriorating patient.  Charlie's case highlights the need for Bamaga Hospital to ensure staff are trained in the application of these tools, with usage monitored and corrective action promptly undertaken when poor compliance is detected.
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