Deceased
RD
Demographics
7y, female
Date of death
2019-09-16
Finding date
2025-04-04
Cause of death
Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
AI-generated summary
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 September 2019. NSW Ambulance protocols clearly indicated transport was required for vital signs in the 'red zone', but paramedics did not consult these protocols. The decision not to transport was a missed opportunity for observation and assessment. Contributing factors included paramedic fatigue from extended shift patterns, insufficient training frequency (18-monthly in 2019), lack of accessible protocol references at point of care, and absence of automated alerts for abnormal vital signs. The coroner recommended developing point-of-care visual prompts when vital signs fall outside normal limits.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
58y · Male·Gunshot injury to the abdomen
David Gray, 58, deliberately induced police to shoot him as a means of suicide following undisclosed mental health deterioration. On 22 September 2023, he called police anonymously reporting an armed person, then present…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —