Coronial
NTcommunity

Inquest into the death of Toddler R

Deceased

Toddler R

Demographics

3y, male

Date of death

2023-04-14

Finding date

2023

Cause of death

Disseminated Staphylococcus aureus infection

AI-generated summary

A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethargy and respiratory symptoms but was not reviewed immediately. On 14 April with obvious signs of severe illness (fever, swollen hand, torso tenderness), sepsis recognition was delayed. The District Medical Officer was not consulted until 11:25am, and despite fever and respiratory distress noted at 1pm, there was a delay exceeding 1 hour before escalation to CareFlight. Critical clinical lessons include: early sepsis recognition in community settings is essential; fever with systemic signs requires urgent evaluation and escalation; remote location workload constraints and multiple IT systems compromised clinical oversight; and staff must maintain heightened vigilance for deteriorating children with repeated presentations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepaediatricsinfectious diseasesemergency medicine

Error types

diagnosticdelaycommunicationsystem

Drugs involved

paracetamolibuprofenpenicillinlidocainerocuronium

Clinical conditions

sepsisdisseminated staphylococcal infectionpyomyositismyonecrosisstaphylococcal bacteraemiarespiratory distress

Procedures

cardiopulmonary resuscitation

Contributing factors

  • Delayed recognition of sepsis
  • Sepsis management targets delayed or not met
  • Inadequate handover documentation
  • Remote location with considerable distance to definitive care
  • Limited after-hours clinical capacity
  • Staff with variable experience and time constraints
  • Limited pathology investigation resources
  • No doctor on site at clinic
  • Potential gap from DMO referral to medical retrieval consultation
  • High clinic workload (23 incoming calls during monitoring period)
  • Clinical records held across multiple databases with incomplete publication to electronic health record
  • Absence of visual cues due to tele-consulting

Coroner's recommendations

  1. The Northern Territory Department of Health encourage all Northern Territory Aboriginal Health Organisations to be aware of the Paediatric Sepsis Recognition and Management Primary Health Care NT Health Guidelines and Sepsis Pathway and for it to be implemented in all health care software systems
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