Coronial
QLDhospital

LM - Non-inquest findings

Deceased

LM

Demographics

1y, female

Date of death

2016-08-25

Finding date

2018-05-04

Cause of death

Sepsis (Group A Streptococcus)

AI-generated summary

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral upper respiratory tract infection symptoms and chronic impetigo. Although GP management was deemed appropriate by independent review, critical delays occurred at the hospital: delayed recognition of septic shock, delayed intravenous access (three hours), delayed antibiotics and fluid resuscitation, and delayed retrieval initiation. The child deteriorated acutely with petechial haemorrhages and shock, ultimately developing bilateral cerebral infarction despite intensive care. Key lessons include implementing paediatric early warning tools (CEWT), sepsis pathways, intraosseous access protocols when IV access fails, and senior-led retrieval for critically unwell children. Early recognition and rapid intervention could have optimised care, though outcome uncertainty remains.

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

Specialties

general practiceemergency medicineintensive careinfectious diseasesretrieval medicinepaediatrics

Error types

diagnosticdelaysystem

Drugs involved

mupirocinerythromycinchloramphenicolceftriaxonecefotaximelincomycinparacetamolibuprofenaerius

Clinical conditions

group a streptococcal sepsisimpetigoseptic shockpetechial haemorrhagespurpura fulminanscerebral ischaemiacoagulopathymetabolic acidosismulti-organ failureupper respiratory tract infectionviral respiratory infectionskin infection

Procedures

scalp cannula insertionintravenous accessintubationintra-osseous accessVA-ECMO cannulationCT brain imagingpost-mortem MRI

Contributing factors

  • delayed recognition of septic shock at regional private hospital
  • delayed intravenous access (three hours)
  • delayed administration of antibiotics and fluid resuscitation
  • delayed initiation of retrieval services
  • absence of paediatric early warning tool (CEWT) at time of presentation
  • difficulty obtaining intravenous access
  • lack of intraosseous access protocol
  • extended scene time during retrieval
  • junior retrieval team not senior enough for timely decision-making
  • lack of local specialist support at regional private hospital
  • Telemedicine unavailable at regional private hospital
  • road retrieval without Code 1 (lights and sirens) status
  • chronic impetigo with uncertain source of streptococcal infection

Coroner's recommendations

  1. Regional private hospital to implement Children's Early Warning Tool (CEWT) for all paediatric patients
  2. Regional private hospital to implement paediatric sepsis pathway for emergency department presentations
  3. Regional private hospital to move urgently (within 15 minutes) to intraosseous access in cases of difficult intravenous access
  4. Regional private hospital to implement NSW Paediatric Sepsis Pathway with early intramuscular antibiotic cover
  5. Regional private hospital to ensure critically unwell paediatric patients are managed in intensive care unit with paediatric nurse support and on-site paediatrician pending retrieval
  6. Regional private hospital to licence intensive care unit for provision of care to sick children awaiting retrieval
  7. More senior staff to be tasked with paediatric retrievals to facilitate timely decisions and shorter scene times
  8. Ambulance services to use Code 1 (lights and sirens) for urgent paediatric retrievals
  9. Establishment and development of nationally recognised clinical standards for sepsis detection and treatment
  10. Development of statewide paediatric sepsis pathway to support early recognition and management in emergency departments
  11. Digital sepsis module to be incorporated into Queensland hospital electronic record systems
  12. Continued implementation of Statewide Sepsis Steering Committee initiatives for paediatric and adult sepsis
  13. Telemedicine availability at regional hospitals for specialist consultation
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