Coronial
VIChospital

Finding into death of Mohammed Tartourssi

Deceased

Mohammed TARTOUSSI

Demographics

3y, male

Coroner

State Coroner Judge Ian L Gray

Date of death

2003-06-28

Finding date

2003-06-29

Cause of death

unascertained

AI-generated summary

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.

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

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

  1. That the Tartoussi family consider consulting specialist genetic services for diagnostic, family health, and/or disease prevention advice
  2. 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
Full text

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