Logan Scott Fergusson: Six-week-old baby boy died after heart scan wasn’t immediately ordered and his death was ‘potentially preventable’, inquest finds

The death of a six-week-old baby in a major hospital was “potentially preventable,” a coroner has determined.

‘Brave but very sick’ Logan Scott Fergusson was born on April 29, 2016 with severe heart defects at Adelaide Women’s and Children’s Hospital (AWCH).

Just four days later, he was flown to the Royal Children’s Hospital Melbourne (RCHM) for urgent heart surgery, returning a month later to the hospital in Adelaide where he had been born before being discharged on June 3.

The young baby was due to return to the AWCH on June 14 after complications, and despite his oxygen level being between 65 and 73 percent, an echocardiogram, which measures how blood is pumping through the heart, was not ordered until the following morning.

While monitoring Logan’s oxygen level at night, they established an accepted saturation level of 65 percent. A healthy person should have an oxygen saturation level of at least 95 percent.

18 shots were taken during the night, 13 fell below the 65 percent threshold and one reached a low of 40 percent.

When Logan was taken for his echocardiogram, it turned out there was a narrowing of his left pulmonary artery, requiring further surgery.

However, it was too late for the boy, who soon after 11 a.m. that day deteriorated and stopped breathing.

His death was found to be caused by hypoxia and decreased lung perfusion, complicating congenital heart disease.

In reporting his findings, Deputy State Coroner Ian White noted that Logan’s death was “potentially preventable,” but could not say it was “certainly” preventable.

Logan Scott Fergusson was born on April 29, 2016 with severe heart defects at Adelaide Women’s and Children’s Hospital (AWCH)

Logan’s death was found to be caused by hypoxia and decreased lung perfusion, complicating congenital heart disease

Mr White felt it was ‘preferable’ that Logan had an echocardiogram when he presented to the emergency department.

“I think it was likely that an echocardiogram would probably have identified left pulmonary artery narrowing if it had been performed earlier,” he said.

Despite this, the coroner could not say with certainty that Logan would be stabilized for the transfer from Adelaide to Melbourne. There was no assurance that the operation would have been successful.

“Logan must have been a very sick little boy. If more was done earlier in terms of improving care through empirical therapies, then he had a better chance of being stabilized enough for a return to RCHM,” he said.

He made no recommendations.