The parents of eight-month-old Willow Katarina Horne are seeking a coronial inquest into her death at Kalgoorlie Health Campus on September 9 last year. A clinical review led by the WA Country Health Service was unable to determine a cause of death, though a panel of six healthcare professionals suggested the infant likely suffered from myocarditis. Willow’s parents, Kaydence Sutherland and William Horne, state they feel failed by the system, citing concerns that their daughter’s condition was not addressed with sufficient urgency before she went into cardiac arrest.
Did You Know? The clinical review panel that examined Willow’s case included a paediatric intensive care specialist, yet the final report concluded there was no suggestion of medical negligence or malpractice among the staff involved.
Findings of the Clinical Review
Helen Van Gessel, executive director of clinical excellence at the WA Country Health Service, led the investigation into the infant’s care. According to the report, the aeromedical retrieval network faced limitations at the time, specifically the absence of a flight medical officer, which prevented a plane from being available to transport the child to Perth Children’s Hospital. The panel noted that earlier awareness of this staffing gap could have provided an opportunity to implement mitigation strategies.
The internal review identified three specific management problems that potentially impacted the outcome: insufficient consideration of alternate diagnosis, a response to physiological deterioration not consistent with policy, and limited shared situational awareness across clinical and coordination teams. Dr. Van Gessel stated that seven recommendations arising from these findings have been accepted and are largely implemented.
Expert Insight: The Stakes of Regional Care
The reliance on aeromedical retrieval in regional Western Australia creates a distinct clinical vulnerability: when the logistics of transport fail, the standard of care is effectively capped by the local facility’s immediate capacity. In this case, the gap between a patient’s deterioration and the availability of specialized tertiary care in Perth highlights the critical importance of situational awareness and the potential for systemic, rather than individual, failures to impact patient survival.
Next Steps for the Family
A coronial inquest is likely to occur, as such cases are typically referred to the coroner for further investigation. Dr. Van Gessel confirmed that police have started an investigation into the matter. WA’s Deputy Premier, Rita Saffioti, stated that she is in discussions with the Minister for Health regarding an inquest and noted that the government would welcome one. For the parents, the process remains a search for accountability regarding the care their daughter received in her final hours.
Frequently Asked Questions
What is the suspected cause of death?
While no official cause of death has been confirmed, the clinical review panel formed the view that Willow likely died from myocarditis, an inflammation of the heart muscle often caused by a viral infection.
Were any staff disciplined after the review?
No. Dr. Van Gessel stated that no staff members were reprimanded and that the panel found no suggestion of medical negligence or malpractice.
Why was Willow not transferred to Perth?
The aeromedical retrieval network was operating under constraints at the time, specifically the absence of a flight medical officer, which resulted in a plane being unavailable for her transfer.
What additional measures do you believe should be prioritized to ensure the safety of infants in regional emergency departments?
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