Inquest into the death of RD
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
Contributing factors
- Paramedics failed to consult NSW Ambulance protocols despite recording vital signs in red zone
- Elevated heart rate (172-168 bpm) not recognized as indicator of serious illness requiring transport
- Paramedic fatigue from extended shift patterns and on-call requirements
- Insufficient training frequency (18-monthly in 2019) on protocols and referral decisions
- Protocols available only in hard-copy folders, not accessible at point of care
- Absence of automated alerts or visual prompts for abnormal vital signs
- Anxiety attributed to elevated heart rate rather than investigation of underlying cause
- No specific discussion with parents about warning signs or deterioration criteria
Coroner's recommendations
- NSW Ambulance should consider developing a feature in current or future NSW Ambulance systems used at point of care, whereby a visual prompt or alert is activated where a patient's vital signs are outside normal limits and/or requires transport to hospital, in accordance with relevant protocols or clinical practice guidelines
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