Finding into death of Lachlan Black
Deceased
Lachlan Black
Demographics
2y, male
Date of death
2014-08-18
Finding date
2017-12-13
Cause of death
Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococcal infection and streptococcal toxic shock syndrome)
AI-generated summary
A 2-year-7-month-old boy died of Group A Streptococcal septicaemia after three presentations to hospital over three days. Clinical staff failed to recognise the developing bacterial infection despite objective warning signs. Key failures included: not escalating care when presented with persistent tachycardia (HR 180) on the third visit; failure to repeat vital signs within one hour to confirm the tachycardia; failure to examine and reassess after petechial rash appeared; and not taking baseline blood pressure until 8pm. Although antibiotics were eventually ordered at 8.30pm, there was a two-hour delay before administration. Had care been escalated when tachycardia was first identified, blood tests obtained by 2-4:30pm, and antibiotics given within 30-60 minutes, survival rates for invasive streptococcal infection are 90-95%. The coroner found shortfalls constituted departure from reasonable standard of care caused by human error and system failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to escalate care when tachycardia of 180 bpm was identified at 1.12pm despite Mandatory Alert Criteria that should have triggered escalation
- Failure to repeat vital signs within one hour of initial presentation to confirm persistent tachycardia
- Cognitive bias towards viral illness diagnosis without adequate consideration of bacterial infection despite third presentation within 3 days, persistent fever history, difficulty walking, and elevated heart rate
- Failure to take baseline blood pressure until 8pm (normal for age group so warning sign missed)
- Failure to examine and reassess after petechial rash was discovered following tourniquet removal at approximately 5.30pm
- Failure to order venous blood gas testing with initial blood tests (would have provided result ~5.30pm showing metabolic acidosis and elevated lactate)
- Delayed administration of antibiotics: verbal order given at 8.30pm but not administered until 10.35pm (2 hour delay)
- Failure to close the loop on verbal antibiotic order to ensure administration
- System failure: ED Mandatory Alert Procedure existed but was not complied with; vital sign abnormality not communicated appropriately
- Absence of blood pressure monitoring in young child with signs of sepsis
- Child appeared well despite critical illness due to advanced sepsis state and afebrile status (lack of fever gave false reassurance)
Coroner's recommendations
- That RACGP, Royal College of Physicians (Paediatric and Child Health Division), and ACEM consider educational opportunities from this case, particularly in relation to recognising sepsis despite absence of fever and despite apparent viral illness
- That Monash Health introduce a policy governing circumstances in which verbal antibiotic orders are acceptable and providing mechanisms to ensure prompt administration, including charting the order at first available opportunity
- That Monash Health introduce a formal policy requiring that patients presenting to ED within 72 hours of previous presentation be personally reviewed by an ED consultant as soon as possible with concerted re-evaluation of working diagnosis; if consultant not available, management by senior registrar with review by second senior registrar
Full text
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