Coroner's Finding: KLINGBERG Briony Caitlin
Deceased
Briony Caitlin Klingberg
Demographics
10y, female
Date of death
2015-01-18
Finding date
2017-02-01
Cause of death
Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection
AI-generated summary
A 10-year-old girl died from multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection. She presented to the Women's and Children's Hospital on day 3 of pharyngitis with ulceration of the tonsillar fossae. The registrar suggested admission for observation and fluids, but the consultant approved discharge with conservative management. The differential diagnosis did not include HSV, and no specific testing for HSV was performed. The girl was subsequently seen by two other doctors who also did not consider HSV. By Friday (day 5), blood tests showed severe liver dysfunction and dehydration but were not acted upon appropriately. Critical failures included: not including HSV in the differential diagnosis for pharyngitis with unusual ulcer distribution; lack of admission despite objective signs warranting it; failure to escalate based on grossly abnormal blood results; and fragmentation of care across multiple providers. Earlier admission and IV hydration, though ultimately likely too late, might have provided a small chance of survival.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- HSV not included in differential diagnosis despite unusual pharyngeal presentation
- Discharge from ED despite registrar recommendation for admission
- No HSV-specific testing despite atypical presentation
- Fragmentation of care across multiple providers
- Failure to escalate based on grossly abnormal blood results on Friday
- Delayed recognition of severity by community practitioners
- Inadequate risk stratification and safety netting at initial ED presentation
- Ambiguous communication regarding need for return or escalation
- Lack of continuity of care leading to incomplete clinical picture
Coroner's recommendations
- The Women's and Children's Hospital should implement a campaign to inform parents of the importance of continuity of care and the risks of breaking that continuity, with a view to encouraging them to return to the Women's and Children's Hospital if they have any doubts about subsequent care, regardless of whether they believe the child is getting worse or merely not getting better
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