Inquest into the death of Child MS

Contributing factors

• failure to use age-appropriate vital sign charts
• repeat vital signs not documented prior to discharge despite initial vitals outside normal range
• immunisation status not up to date (not reflected in risk assessment)
• inadequate safety netting and sepsis recognition education provided to parents
• vital signs consistent with ATS category 3 (urgent) not escalated to ATS 3 classification
• lack of confidence in healthcare provider by parent preventing return to hospital
• gradual progression from viral respiratory infection to secondary bacterial sepsis over 4 days

Coroner's recommendations

1. NT Health implement recommendations from the Structured Judgement Review to educate on importance of using age-specific vital sign charts or stickers for all patients
2. Educate on observation guidelines requiring repeated vital signs for patients with vitals outside normal range
3. Consider using fact sheets and handouts to support discharge advice with documentation of their provision
4. Use Royal Children's Hospital fever fact sheet or viral illness fact sheet, particularly for families where English is not first language
5. NT Health review including immunisation status in risk factors section on paediatric sepsis form as potential red flag for higher sepsis risk