Mohammed Tartoussi, aged 3 years 11 months, presented to Bell Street Family Medical Centre on 28 June 2003 with chest pain and mild upper respiratory symptoms. He was diagnosed with mild symptoms and given prednisolone. That evening, he experienced sudden apnoea and died despite CPR. His cause of death was unascertained at autopsy. Clinical lessons include: (1) the challenge of recognising genuinely concerning symptoms amidst frequent presentations (mother had presented him 179 times with 36 different doctors); (2) the missed opportunity to take chest pain more seriously in a child with respiratory symptoms and asthma history; (3) the need for systems to flag multiple medical presentations to alert clinicians to underlying family or medical issues requiring investigation; and (4) better coordination between multiple healthcare providers. The coroner noted the mother exhibited health anxiety and symptom exaggeration, though not intentional fabrication.
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Specialties
emergency medicinepaediatricsgeneral practicecardiologyrespiratory medicineforensic medicine
Error types
diagnosticsystemcommunication
Drugs involved
salbutamolprednisolonefluticasone/salmeterol
Clinical conditions
asthmaupper respiratory tract infectionsudden unexplained death in childhoodpossible epilepsy
Contributing factors
sudden unexplained death in childhood, possible undiagnosed epilepsy
asthma with recent acute exacerbation
upper respiratory tract infection
missed opportunities for early identification and investigation due to fragmented care across multiple providers
lack of system to coordinate multiple medical presentations
Coroner's recommendations
That the Tartoussi family consider consulting specialist genetic services for diagnostic, family health, and/or disease prevention advice
That 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 establishment of a system (similar to Medicare's Prescription Shopping Program) to identify excessive medical presentations of children across multiple practitioners and locations
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