Deceased
Master T
Demographics
1y, male
Coroner
Coroner Sarah Gebert
Date of death
2019-11-25
Finding date
2023-01-25
Cause of death
Chronic Bronchial Asthma
AI-generated summary
Master T, a 17-month-old boy with chronic asthma, died from status asthmaticus on 25 November 2019. He had experienced recurrent wheezing episodes requiring multiple hospital admissions in September-October 2019. Medical management followed recognised guidelines with bronchodilators and corticosteroids. A critical system failure was identified: RCH prescribed montelukast on discharge (18 September 2019) and sent referral via fax to TNH, but the fax was incompletely received (missing cover page). TNH did not register the referral on their system, and the GP did not confirm montelukast was being administered. While the CPU concluded montelukast likely would not have changed the outcome, this communication failure represents a preventable system error. The case highlights ongoing risks with facsimile communication in healthcare despite previous coronial recommendations. Environmental smoke exposure (methamphetamine and cannabis residues detected) likely triggered asthma exacerbations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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