Finding into death of Makayla Lee Wadeson
Deceased
Makayla Lee Wadeson
Demographics
9y, female
Coroner
Coroner Dimitra Dubrow
Date of death
2022-08-01
Finding date
2024-10-10
Cause of death
Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl with pulmonary thromboembolism and deep vein thrombosis
AI-generated summary
Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and discharged with a diagnosis of otitis externa after a 40-minute wait. Critical clinical lessons: her elevated heart rate (146 bpm) at triage was not recognised as abnormal, she should have been triaged Category 3, her immunosuppressed status was not documented in the ED record despite being on immunosuppressants for ulcerative colitis, and no repeat observations were performed despite policy requirements. She deteriorated at home and died two days later from pneumonia caused by Streptococcus pneumoniae and Candida albicans with concurrent pulmonary thromboembolism and DVT. The coroner identified that recognition of her abnormal vital signs and appropriate escalation of observations may have prevented her death through earlier detection of systemic illness.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to recognise elevated heart rate (146 bpm) as abnormal
- Under-triage: assigned Category 4 instead of Category 3
- Immunosuppressed status not documented in ED record despite active immunosuppressive therapy
- No repeat vital signs or observations taken during ED attendance
- Observations not recorded on ViCTOR (Victorian Children's Tool for Observation and Response) chart
- Electronic medical record system fragmentation preventing access to current diagnoses and medications
- Potential rapid deterioration after discharge not detected due to lack of follow-up observations
Coroner's recommendations
- That GV Health use ViCTOR charts to record all observations in paediatric cases including observations taken at triage in the emergency department
- That GV Health make changes to their electronic medical record to ensure current medical diagnoses and medications are easily accessible to all users who open the record
Full text
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