Inquest into the death of BR

AI-generated summary

A 12-month-old infant suffered unexpected cardiac arrest at home nine days after receiving routine MMR, meningococcal, and pneumococcal vaccinations. He presented to Manning Base Hospital on 27 July 2020 with fever (38.5°C) and rash; was triaged as semi-urgent, waited nearly 4 hours, and was discharged at 10:15pm after assessment by the Senior Medical Officer found mild viral illness signs that had largely resolved. Mother called back at 1:57am reporting fever of 38.8°C but was reportedly told no beds available until morning. At 2:07am, the infant suffered cardiac arrest at home; resuscitation efforts continued but he died on 29 July after anoxic brain injury. Post-mortem examination and extensive investigations could not establish a definitive cause. Expert review found the initial discharge decision reasonable given the mild presentation, though discharge safety-netting documentation was lacking. The hospital subsequently implemented improved discharge protocols, ED telephone advice scripts, and adopted febrile child guidelines. The ultimate cause of cardiac arrest—epileptic, cardiac, viral, bacterial, or vaccine-related—remains unascertained.

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