Coronial
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C - Non-inquest findings

Demographics

6y, male

Coroner

Kirkegaard

Date of death

2017-01-14

Finding date

2020-09-07

Cause of death

Sepsis due to melioidosis

AI-generated summary

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagnosis of viral gastroenteritis was reasonable given the rarity of melioidosis in children and the clinical presentation. However, systemic failures hindered optimal care: absent clinical documentation of presentations on 5–8 January, failure to reassess or involve a doctor over the weekend despite parental concern, and a five-hour delay in commencing intravenous antibiotics after admission on 10 January. The child was transferred to a regional hospital and then to a tertiary paediatric ICU, but despite maximal intensive care including ECMO, he developed septic shock, pneumonia, ARDS, multiorgan failure, and ultimately brain death. Key learning points include implementing structured sepsis pathways in rural settings, ensuring proper documentation and escalation protocols, and recognizing parental concern as a clinical trigger for reassessment.

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

Specialties

paediatricsinfectious diseasesintensive careemergency medicineretrieval medicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

paracetamolibuprofenceftriaxonemeropenemvancomycinlincomycinerythromycinazithromycin

Clinical conditions

melioidosissepsisseptic shockpneumoniaacute respiratory distress syndromemulti-organ failureviral gastroenteritisdehydrationfever

Procedures

intubationmechanical ventilationextracorporeal membrane oxygenation (ECMO)chest X-rayultrasoundCT brain imagingblood cultureurine analysis

Contributing factors

  • Absent or incomplete clinical documentation of presentations on 5–8 January 2017
  • Failure to assess or escalate care over the weekend (7–8 January) despite parental concern and clinical deterioration
  • Delayed medical review and prioritization on 10 January 2017
  • Approximately five-hour delay in commencing intravenous antibiotics after admission on 10 January
  • Lack of a structured sepsis clinical pathway at the remote hospital
  • Systemic failures in record keeping and use of early warning tools
  • Use of short-term locum medical officers without continuity of care
  • Absence of a specific melioidosis alert or infectious disease consultation protocol

Coroner's recommendations

  1. Implementation of Rural & Remote Emergency Department Paediatric Sepsis Pathways to improve early recognition and treatment of sepsis in children
  2. Improved clinical record keeping and documentation standards at remote hospitals
  3. Proper use of early warning and response observation tools (Children's Early Warning Tool, CWET) and escalation protocols
  4. Implementation of structured sepsis clinical pathways that include consideration of melioidosis in endemic areas
  5. Use of Ryan's Rule to enable escalation when clinical concern persists
  6. Adequate medical staffing with permanent positions rather than reliance on short-term locum doctors
  7. Establishment of senior medical review protocols for children with repeated presentations and parental concern
  8. Incorporation of a digital sepsis module into the iEMR system across Queensland public hospitals
  9. Training for clinicians in rural and remote settings on sepsis recognition, particularly in endemic regions
  10. Regular consultation with paediatric infectious diseases specialists for diagnostic uncertainty in endemic conditions
Full text
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