Demographics
0y, unknown
Date of death
2019-09-23
Finding date
2021-08-26
Cause of death
sepsis leading to multiple organ failure syndrome
AI-generated summary
A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw the patient after 51 minutes. Despite a Children's Early Warning Tool score of 7 requiring review within 15 minutes and full blood pressure measurement, neither occurred. Full observations were not recorded; paracetamol was given while waiting. The paediatric registrar could not achieve IV access at 3.00pm. A senior registrar was not called until 5.00pm, causing critical delays in diagnosis and treatment of sepsis secondary to bowel obstruction. The child's congenital heart condition may have distracted clinicians from recognising the acute bacterial infection. Surgical intervention occurred too late. The child died of sepsis and multiple organ failure. Earlier recognition, appropriate escalation, timely IV access, and senior involvement could potentially have altered the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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