VIChospital

Finding into death of Zakaria Tartourssi

Deceased

Zakaria Tartoussi

Demographics

0y, male

Coroner

State Coroner Judge Ian L Gray

Date of death

2002-11-27

Finding date

2009-01-27

Cause of death

Respiratory insufficiency; interstitial fibrosis and low-grade pneumonitis of probable viral aetiology

AI-generated summary

Zakaria Tartoussi died at age 43 days from respiratory insufficiency due to interstitial fibrosis and low-grade pneumonitis of probable viral aetiology. He presented for medical attention five times in six weeks with symptoms including nasal congestion, cough, blue lips during feeding, and general unwellness. A forensic paediatrician opined that pneumonitis was likely developing during this period and that chest examination may have revealed abnormalities, particularly in the final week of life. Multiple medical consultations failed to recognise respiratory distress or perform adequate chest examination. This represents a missed diagnostic opportunity: more thorough clinical examination, particularly auscultation of the chest, at any of the presentations may have identified the developing respiratory infection before terminal deterioration occurred.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepaediatricsobstetricsemergency medicine

Error types

diagnosticcommunicationsystem

Drugs involved

paracetamol

Clinical conditions

viral upper respiratory tract infectionpneumonitisinterstitial fibrosisrespiratory insufficiencycyanosis

Contributing factors

Failure to perform adequate chest examination at multiple medical presentations
Failure to recognise signs of respiratory infection despite repeated presentations with respiratory symptoms
Failure to adequately investigate blue episodes during feeding in context of other respiratory symptoms
Inadequate investigation of maternal concerns about infant's nasal congestion and coughing
Absence of coordination or overview of repeated presentations to multiple healthcare providers

Coroner's recommendations

The Tartoussi family consider consulting specialist genetic services for diagnostic, family health, and/or disease prevention advice
The Minister for Health consider improvements in the way data regarding presentation for medical care can be accessed/shared by medical professionals to assist with patient evaluation and care, including systems to identify children with multiple presentations that may indicate undiagnosed disease, with consideration of the framework outlined in paragraphs 32-38 regarding Medicare reporting systems and privacy legislation

Full text

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