Coronial
VIChospital

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.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinepaediatricsinfectious diseasesrespiratory medicine

Error types

diagnosticsystemcommunication

Drugs involved

cefalexinsofradex ear dropsimmunosuppressive medications for ulcerative colitis

Clinical conditions

pneumoniapleural empyemapulmonary thromboembolismdeep vein thrombosisotitis externaulcerative colitisobesityiron deficiency anaemiaautism

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

  1. That GV Health use ViCTOR charts to record all observations in paediatric cases including observations taken at triage in the emergency department
  2. 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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