Deceased
Adam Michael Francis Fabre
Demographics
19y, male
Coroner
State Coroner Judge Jennifer Coate
Date of death
2006-07-15
Finding date
2010-03-24
Cause of death
acute bacterial meningitis with secondary cerebritis (meningococcus)
AI-generated summary
Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern about his deteriorating condition, both nursing staff and his mother, a junior doctor (Dr D., only 2 weeks in ED) misdiagnosed him with upper respiratory tract infection. The supervising senior doctor (Dr B.) did not personally examine him despite being informed of concerning symptoms, nursing staff expressing concern, and the junior doctor's inexperience. Treatment with IV fluids and analgesia failed to improve his condition, yet the diagnosis was not reassessed. Blood tests taken at 5am were not sent to pathology until 8:30am and would have shown elevated WBC and grossly elevated CRP (239). He seized at ~9am, received antibiotics only then, was intubated and transferred to ICU where he died from meningococcal meningitis with cerebritis on 15 July. Clinical lessons: recognise the constellation of fever, severe pain, headache, neck stiffness and rash as potentially serious; senior doctors must personally review unwell patients, especially when junior staff express concern; reassess diagnosis when treatment fails; understand that blanching rashes do not exclude meningococcal disease; administer antibiotics early in suspected meningitis.
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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53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
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