BY RATTAN MALL

THE report by a coroner on the death of three-year-old Nimrat Kaur Gill at Abbotsford Regional Hospital last February says what the hospital had concluded last April.

The girl’s mother, Balraj Gill, told a South Asian radio back in February after the heart-wrenching tragedy that if the doctors had examined her daughter properly the first time they went to hospital, she would have still been alive.

And it does seem that was true as the hospital told The VOICE on Thursday that they have “identified a number of action items to improve patient care and outcomes.” Quite obviously, some crucial aspects of their training were missing.

Last April, Fraser Health told the media that the laboratory test results indicated that the girl had “a fast-moving and aggressive bacterial infection known as invasive group A streptococcal disease.”

It said that Group A streptococcal disease usually causes mild illnesses such as strep throat or a mild skin infection, but could on rare occasions also invade parts of the body where the bacteria are not found — such as the lungs or blood — and these invasive infections are potentially life-threatening, the CBC reported at the time.

“Given what we know about how aggressive and fast-moving an invasive group A streptococcal infection can be, it cannot be determined if an earlier diagnosis and subsequent treatment would have saved Nimrat’s life,” Fraser Health President and CEO Michael Marchbank said in a statement.

The key word here is “IF.” We will never know, will we?

He added that they had come up with six actions following their review of Gill’s death.

Again, that obviously meant that something was missing in their procedures / training.

THIS week, the Vancouver Sun reported that a report by coroner Adele Lambert states that Nimrat died of sepsis due to a relatively uncommon A Streptococcus infection that progressed rapidly and unexpectedly.

The report said that the girl’s body showed several abnormalities, including a collapsed left lung, acute bronchopneumonia and a urinary tract infection.

But Lambert found that her death was natural.

The girl’s parents had taken her to hospital on February 6. She had a fever, a cough, and had been vomiting. The report said the medical staff found Nimrat was congested, but not in her chest. She was discharged when her temperature returned to normal.

But her condition had worsened by early next morning and she was brought back to the hospital. She was coughing frequently and had vomited several times. She had rapid breathing. However, her chest was clear, according to the report.

Nimrat’s temperature had begun to rise by 6:45 a.m. and she had thrown up several more times. An X-ray revealed that Nimrat was suffering from pneumonia.

The report said that by 10:14 a.m., Nimrat suffered cardio-respiratory arrest. An hour later she was pronounced dead after extensive resuscitation efforts.

ON Thursday, I emailed Fraser Health that I wanted to know if staff at Abbotsford Regional Hospital could not have done a more thorough job in detecting the “rare but aggressive infection.”

And also, if anyone communicated the Coroner’s report to the Gill family and tried to help them cope with this?

Fraser Health forwarded me a statement from Dr. Michael Newton, site medical director at Abbotsford Regional Hospital, in response to my questions, that said:

THE death of a child is a horrible tragedy and our thoughts remain with this family.  While the release of the coroner’s report will not change the outcome, we hope that this furthers their understanding of what happened.

The report made no recommendations for Fraser Health and confirmed the initial findings – that Nimrat died from an invasive group A streptococcal infection which is a rare but aggressive infection for a small child.

Since the report is by the Coroner’s Office, they would share the report with the family and answer any questions they may have.

What I can tell you though, is that following Nimrat’s death, we identified a number of action items to improve patient care and outcomes:

* We continue to offer specialized pediatric education for our Emergency physicians and staff including mock code training. Our simulation lab will open in Spring 2018 to provide regular simulation training in the management of critically ill patients, including pediatric patients.

* We implemented mechanisms to support better collaboration between pediatric and Emergency Department leadership; and enhanced education on standards for clinical documentation.

* We also completed a review and rolled out improvements of shift handover and escalation processes

* And finally, we continue to work on our Triage process to support early identification of critically ill pediatric patients.

These actions mean earlier and more complete diagnosis from teams of highly trained caregivers that work collaboratively and share information resulting in better care and better outcomes for our patients.