Coroner's Finding: MARTIN Kirsten Lee

Contributing factors

• failure to maintain high index of suspicion for meningococcaemia in absence of classic rash
• over-reliance on absence of meningeal signs and rash to exclude diagnosis
• unsubstantiated diagnosis of urinary tract infection as alternative explanation
• failure to obtain senior doctor review before discharge decision
• inexperienced junior doctor (RMO 5 weeks in Australia) not seeking adequate supervision
• consultants not examining patient themselves before giving advice
• premature discharge without admission for observation
• inadequate written communication with family about warning signs requiring return

Coroner's recommendations

1. Minister for Health to facilitate arrangements in emergency departments enabling suitable patients to be admitted for extended care and observation for periods up to 24 hours
2. Minister for Health to ensure emergency department directors produce and prominently display lists of medical practitioners rostered on duty with clear descriptions of status and contact details, kept up to date
3. Minister for Health together with Medical Board to develop strategy alerting medical practitioners in emergency departments and general practice to less typical presentations of meningococcal disease and results of recent English studies on early diagnosis, particularly early sepsis symptoms (leg pain, abnormal skin colour, cold hands and feet)
4. Minister for Health to consult with emergency department directors and infectious diseases specialists to review current approach to administration of antibiotics in suspected meningococcaemia