Finding into death of Sasha
Deceased
Sasha
Demographics
12y, female
Date of death
2019-08-02
Finding date
2023-07-17
Cause of death
Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) in the setting of bicuspid aortic valve, pneumonia, pneumococcal septic shock and influenza B infection
AI-generated summary
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite high inflammatory markers and blood culture eventually showing pneumococcal infection, she was diagnosed with viral illness. Critical factors included: a 9-hour delay between pathology faxing positive blood culture results (1:22am) and medical notification (10:49am); failure to consider endocarditis despite cardiac history in her father; and reliance on facsimile as sole communication method. The child developed an aortic root abscess causing septic shock, cardiac arrest, and eventually hypoxic-ischaemic brain death. Medical experts agreed antibiotics alone (even if started earlier) would not have prevented the abscess. Expert opinion differed on early empiric antibiotics, with consensus that endocarditis diagnosis was unreasonably difficult given non-specific presentation, normal ECG/imaging, and rarity of pneumococcal endocarditis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Delayed communication of positive blood culture result (9-hour delay from fax at 1:22am to medical notification at 10:49am)
- Reliance on facsimile transmission as sole means of communication of critical pathology results
- Non-specific clinical presentation (viral-like symptoms, intermittent chest pain, abdominal pain) that mimicked viral illness
- Negative influenza test initially misleading but later confirmed positive
- Rapid deterioration once focal pneumococcal infection seeded to aortic valve (within hours)
- Lack of awareness of paternal cardiac history (bicuspid aortic valve with valve replacement) as potential heritable risk factor
- Absence of pathognomonic signs of endocarditis (murmur, persistent fever) in early presentation
- Normal electrocardiogram and chest X-ray not suggestive of cardiac pathology
- Aortic root abscess only discoverable on echocardiogram (not performed until after cardiac arrest at tertiary centre)
Coroner's recommendations
- Department of Families, Fairness and Housing review its Child Protection Manual and other relevant policies or guidelines to include guidance to Child Protection practitioners to seek, where possible, familial medical history that may impact the health of a child in its care
- Department of Families, Fairness and Housing implement a means of effective urgent communication with its case-contracting agencies, supported by appropriate policy and procedures, in respect of a child in care. The means adopted should be available at all hours and capable of actively alerting the recipient
- Department of Families, Fairness and Housing review its Child Protection Manual and other relevant policies or guidelines to make clear to case-contracting agencies, the circumstances in which it expects to urgently receive information concerning a child in care
- Central Gippsland Health Service take all steps as may be required to eliminate facsimile transmission as the sole means of communication of critical clinical information
Full text
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Source and disclaimer
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