Finding into death of Caleb Harley Pearson

Contributing factors

• Paramedics failed to recognise the significance of multiple abnormal vital signs (tachycardia, tachypnoea, hypothermia, signs of dehydration)
• Paramedics did not perform blood glucose testing despite undifferentiated illness presentation
• Misdiagnosis of anxiety and hyperventilation syndrome without adequate differential diagnosis
• Cognitive bias from recent GP diagnosis of pharyngitis
• Paramedics' limited training in recognition of undifferentiated illness and occult diagnoses
• Inadequate assessment to confirm or exclude proposed diagnoses
• Failure to recognise that persistent abnormal respiratory rate (24-40 bpm) warranted hospital transfer
• NHDS triage operator failed to recognise gravity of symptoms (rapid breathing, altered responsiveness) and did not advise caller to contact 000
• NHDS operator failed to document all reported symptoms and apparently ignored or missed the altered respiratory rate report
• Delayed dispatch of NHDS doctor (dispatched around 3am rather than immediately)
• Undiagnosed Type 1 diabetes mellitus

Coroner's recommendations

1. Ambulance Victoria should consider changing their Clinical Practice Guidelines to require paramedics to measure blood glucose level of any patient presenting as acutely unwell, particularly in the setting of undifferentiated illness