Finding into death of Leroy William Scott

Contributing factors

• Inadequate triage (Category 4 assigned despite fever 38.1°C and lethargy)
• Eight-hour delay from presentation to first medical review
• Failure to act on preliminary positive blood culture result (gram-positive cocci)
• Failure to act on elevated CRP result (103.7)
• Failure to repeat CRP testing to reassess clinical trajectory
• Failure to enquire about time-to-positivity of blood culture (9 hours 41 minutes - highly suggestive of true pathogen)
• Failure to commence empirical antibiotics despite unresolved blood culture results and objective markers of infection
• Laboratory delay in commencing coagulase test (4 hours after gram-stain result available)
• Laboratory failure to read coagulase test results at 2-hour and 4-hour intervals before staff departure
• Poor communication between pathology and clinical teams regarding test status and availability
• Inadequate handover of information regarding blood culture results between Dr Athan (infectious diseases) and treating paediatric team
• Misunderstanding regarding laboratory hours of operation on public holidays

Coroner's recommendations

1. Clearer protocols between hospital and pathology regarding hours of operation on public holidays/weekends
2. Clearer protocols providing on-call scientist name and contact details for urgent blood results on evenings, weekends, and public holidays
3. St John of God Pathology should inform Barwon Health via on-call physician if coagulase test commences less than 2 hours before staff departure, enabling decision on whether on-call scientist needed
4. Same notification protocol if 2-hour result known but laboratory closing before 4-hour result due
5. On-call physician to relay such information to treating team