Shaun Bell was four years old when he died on 14 March 2016 at Tweed Heads Hospital as a result of peritoneal sepsis caused by a perforated duodenal ulcer. His case illustrated the difficulties associated with diagnosing and treating special needs children and the risk of 'group think phenomenon' amongst doctors.

Background Facts

When Shaun was two years old, he was diagnosed with significant global developmental delay. Twelve months later, he was found to have a severe language expressive disorder and severe development coordination disorder. He commenced speech pathology, which included learning sign language.

On 9 March 2016, Shaun's mother took him to the GP. He had been lethargic for days, had been vomiting and not eating. The GP diagnosed a viral illness. Two days later, she phoned the 13 Health triaging service and advised them that he continued to be lethargic, had not eaten or had a bowel movement in days and, when asked whether he had abdominal pain, noted that he was a special needs child but that he had communicated in sign language that he did not have any pain. The 13 Health nurse advised Shaun's mother to wait two or three more days and to take him to the doctor if he had not 'turned a corner' by then.

Shaun's mother called 13 Health two days later and described his lethargy as being as though he was 'hibernating'. She said that his legs weren't working properly. The nurse advised Shaun's mother to take him to the hospital, given that he was a special needs child and unable to properly communicate whether he was in pain.

Shaun was assessed by the Resident in the Emergency Department (ED) 15 minutes after his arrival. As he was relatively inexperienced, the Resident sought advice from the ED Consultant on duty. Both doctors thought that Shaun was very unwell and were concerned that he had not eaten for 7 days. A number of tests were ordered.

Shaun was transferred to the paediatric department. His treating team settled on a provisional working diagnosis of gastroenteritis with associated dehydration. Test results later showed abnormalities including a low haemoglobin and sodium level count and elevated white blood cell count. These abnormalities were put down to his vomiting. The treating team did not consider that Shaun should be moved to a more specialist hospital, with higher level paediatric services. Later that night, Shaun vomited a substance found to contain blood. Further blood tests received showed an increase in Shaun's white cell count and neutrophils.

On the morning of 14 March 2016, Shaun was very agitated. The nurses had not taken all of his observations throughout the night in an attempt to avoid further agitating him. This continued into the morning. The paediatrics Registrar stated that she understood from her handover that Shaun was unwell, but not critically so. Noting further test results, she formulated a plan for him to be examined by the paediatrics Consultant when he arrived.

Upon his arrival, the Consultant was not able to rouse Shaun from sleep and he shortly went into cardiac arrest. An ultrasound showed that he had large amounts of blood or pus in his abdomen. As he was too unstable to be moved to another facility, a laparotomy was performed which revealed a perforated duodenal ulcer. The perforation was closed and fluid washed out, however Shaun continued to have cardiac arrests. He remained in a critical condition and his family made the decision not to resuscitate him when he deteriorated further.


The Coroner considered whether anything could have been done to prevent Shaun's death at any stage in the treatment process.

A number of clinicians gave evidence. The experts were not critical of the failure to diagnose the perforated ulcer, given the rarity of the condition in young children. However, they weremedical staff, critical of the failure to recognise that Shaun was critically ill. This, in turn, prevented them from taking urgent action to identify the cause. This was a collective failure of all the doctors involved, which one expert put down to 'group think phenomenon' whereby clinicians involved in a patient's care become blinded to certain abnormalities.

While in the ED, the doctor should have taken the initiative to transfer him to a higher care hospital. His first blood test should have prompted urgent enquiry. It was noted that the difficulties in treating Shaun were made more difficult by the fact that he could not verbalise. The experts also noted that while the paediatric doctor carried out a thorough examination and history, and noted abnormalities, they didn't attempt to formulate a different diagnosis in light of these abnormalities. The experts were critical of the doctor's lack of response to Shaun's high pulse rate, which he put down to agitation.

The response of the Registrar on the day of Shaun's death exemplified the 'group think phenomenon'. While the handover had caused her to believe that Shaun was not critically ill, the experts noted that there was nothing preventing her from examining his test results and undertaking her own assessment. Criticism was also made of the nursing staff who neglected to take Shaun's observation as often as was mandated because they did not want to further agitate him.

In relation to the first 13 Health call made, the Coroner identified gaps the training of 13 Health nurses in relation to children with special needs.


It was considered that it would be unfair and problematic to single out any particular doctor for personal recommendations. Tweed Hospital acknowledged systemic shortcomings and listed the changes which had already been made, which obviated the need for further recommendations to be made. These included:

  • adding a second ED consultant to the evening shift roster;
  • changing hospital protocols, such that if a child presents to the ED with significant electrolyte or other haematological abnormality, a disability, or undifferentiated diagnosis, the consultant paediatrician on call must review the child in the ED prior to transfer or discharge;
  • introducing assertiveness training for nurses and junior medical staff;
  • prohibiting changes to the frequency of observations without a documented discussion with the paediatrician on call; and
  • using Shaun's case to educate clinicians at the hospital about managing deteriorating child patients.

The Inquest also heard details of a new education package, developed for tele triage staff at 13 Health and designed to help provide advice to patients with developmental delay and ensure that nurses prompt patient's with developmental delay to have a face-to-face assessment. It was further recommended that educational sessions based on this matter be provided and a policy be implemented, requiring nurses to consult in cases of a developmentally delayed patient.