A labelling mix-up at Sydney Children's Hospital led to a potentially risky operation that killed a one-month-old baby, a coronial inquest has heard.
Joshua Elliott died at the hospital on September 9, 2009, after a catheter perforated a vein and leaked nutritional fluid into his chest.
Paediatric anaesthetist Maged Bishay told an inquest into the death that he placed a 2.5 french catheter, measuring about 0.09 millimetres in diameter, into Joshua's body.
This was because his preferred 3 french size, which was one millimetre wide, could not be found.
The smaller tube was likely to have been slightly stiffer than the wider version and therefore carried a higher risk of perforating Joshua's vein, Dr Bishay told Glebe Coroner's Court.
"It certainly carried a higher risk," he said.
The hospital's assistant director of clinical governance, Jonathan Taitz, said the larger catheter tube was available on the day of the operation but it was not found because it was incorrectly labelled.
"There were in fact 3 french catheters available in the operating theatre, but they weren't correctly labelled," Dr Taitz said.
Joshua's death, and that of 10-month-old Tama Galiere, should be a wake-up call for medical staff, he said.
Tama suffered a cardiac arrest and died at Sydney Children's Hospital on June 25, 2008, after a catheter was put into his arm as part of his treatment for an eye infection.
"I think Joshua's death has been absolutely catastrophic for the family and incredibly traumatic for all the practitioners, particularly falling within 12 months after the Galiere matter," Dr Taitz said.
"If ever practitioners needed any reminding about the importance of guidelines and the importance of sticking to them, these are two very salient reminders."
An inquest into Tama's death is due to reconvene on March 30 at the same court.
Dr Taitz said changes had already been made at Sydney Children's Hospital to try to prevent further labelling mix-ups.
Joshua was born on August 9, 2009, with gastroschisis, an intestinal defect. He was treated successfully for the condition but struggled to gain weight.
Dr Bishay told the inquest he'd had several concerns about Joshua's health prior to the September 8 operation.
The baby boy had been vomiting, suffering fevers and low blood-sugar levels, Dr Bishay said.
Access to Joshua's veins had been problematic during previous procedures, he said.
Asked why the operation was not aborted once it appeared only the one millimetre wide catheter was available, Dr Bishay said it would have been undesirable to put Joshua through another operation at a later stage.
The inquest before deputy state coroner Scott Mitchell is expected to end on Friday.
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