Deceased
Dio Katiana Miranda Kemp
Demographics
3y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2019-11-29
Finding date
2025-09-25
Cause of death
Streptococcus pyogenes septicaemia
AI-generated summary
A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrhoea. Initial presentations were reasonably attributed to viral illness and her rash was assessed as urticaria rather than erysipelas. However, the clinician managing her second ED presentation failed to consider bacterial infection or follow mandatory re-presentation protocols. The RRC consultant's assessment on day 5 of fever was inadequate without clear escalation guidance to the GP. The GP saw her on days 8 and 9 of fever but lacked hospital guidance about when persistent fever warrants hospital investigation. Critical opportunity for diagnosis and life-saving antibiotics was likely within 48 hours before death, but the clinical picture mimicked uncomplicated viral illness during hospital visits. Improved communication between hospital and primary care about persistent fever red flags is essential.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.