Non-inquest findings into the death of Connor Dean
Deceased
Connor Dean
Demographics
6y, male
Date of death
2024-08-10
Finding date
2026-08-28
Cause of death
Hypoxic-ischaemic encephalopathy due to cardiac arrest following general anaesthetic in the setting of vitamin C deficiency, with Down syndrome as a contributing condition
AI-generated summary
Connor Dean, a 6-year-old with Down syndrome, died following cardiac arrest during an MRI under general anaesthetic. He had severe vitamin C deficiency (scurvy) which was not detected despite clinical and nutritional risk factors. His paediatrician had correctly identified multiple micronutrient deficiencies (vitamins A, B12, D, E, K, and iron) from 2023 onwards and recommended supplementation with a named multivitamin product containing vitamin C. However, the parents administered a different multivitamin product that lacked vitamin C without awareness of this omission. During the MRI procedure on 20 July 2024, he suffered cardiac arrest leading to hypoxic-ischaemic encephalopathy. The coroner found vitamin C deficiency the most likely underlying factor. Clinical lessons: comprehensive micronutrient monitoring in children with poor dietary intake must specifically include vitamin C; clinicians should verify actual product composition when recommending multivitamins, particularly for vulnerable children; product labeling standards for 'multivitamin' designation merit review.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Severe vitamin C deficiency (scurvy)
- General anaesthetic administration during MRI
- Down syndrome
- Poor nutritional intake
- Multivitamin product lacking vitamin C
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