TRAGIC LOSS: Jasmyn Carter, with her mum Jeanella.
TRAGIC LOSS: Jasmyn Carter, with her mum Jeanella. Contributed

The hospital system failed Jasmyn Carter, says coroner

A CORONER said it was a "significant concern" that hospital staff did not phone Jasmyn Louise Carter's mother until she had died from meningococcal septicaemia.

Queensland Deputy State Coroner John Lock yesterday handed down his findings into the death of Jasmyn, and Verris Dawn Wright, who died in Oakey on Boxing Day, 2013.

Jasmyn went to Warwick Hospital's emergency department on August 3, 2014 after playing Aussie rules, with a headache, dizziness and aches in her arms and legs.

She was admitted to a ward overnight and died early the next morning after going into cardiac arrest.

The 17-year-old's mother, Jeanella Carter yesterday told the Daily News she needed time to process the coroner's findings but expressed previously her distress at not having been at her daughter's side when she died.

Family friend Nichole Brack was at Jeanella's side throughout the inquest and yesterday said she was pleased with the outcome.

"(Jeanella and I) have just spoken to the solicitor who has explained everything and I think it is a very good outcome," she said.

"He has said it shows they didn't do the right things in a number of ways and hopefully changes will be made and this won't happen to someone else."

Ms Brack said she agreed with the coroner's finding that Jasmyn's mother should have been notified that her daughter's condition was deteriorating.

"It is disgusting. She is a minor - she was a baby - and she had to lay there and go through that on her own," she said.

"Jeanella goes to bed every night and has to think of what her baby went through when she wasn't there to help her.

"She has told me 'If I was there screaming her name she would have been okay'."

Ms Brack said she believed there would have been plenty of time for Jasmyn's mother to get to her daughter's bedside.

"She was only five minutes down the road - in fact she only took three minutes to get there - she should have been given a chance to get there.

"It would have made the world of difference to a grieving mum.

"I tell you what, she is the strongest woman I know but I can see her breaking."

In Mrs Wright's case, Mr Lock said she was first taken to Oakey Hospital on Christmas Eve 2013 with abdominal pain and was later discharged.

Two days later she went back to hospital and was not seen by a doctor for four hours. She died during this time.

"There were a series of almost unbelievable errors, misunderstandings and miscommunications which contributed to this tragic set of events," Mr Lock said.

He said the nurse had one plan; for the on-call doctor to examine her. Mr Lock said the doctor's phone was not charged and did not receive the nurse's messages.

Mr Lock said this was "inexcusable" and that nurses should have had a Plan B.

Mr Lock said the Darling Downs Hospital and Health Service had implemented a deterioration detection system in their hospitals following the death of Mrs Wright but it was not implemented properly in Jasmyn's case.

He said if it had, an emergency reading would have been made earlier.

Mr Lock recommended that Queensland Health fund research into the deterioration detection tool.

He also said the Darling Downs Hospital and Health Service should consider a protocol for advising family of patients who are deteriorating.

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