Coronial
WAhospital

Inquest into the Death of Malakai Matiu Ward PARAONE

Deceased

Malakai Matiu Ward PARAONE

Demographics

0y, male

Coroner

Deputy State Coroner King

Date of death

2016-08-26

Finding date

2020-09-04

Cause of death

Complications in association with fulminant sepsis in an infant (Streptococcus pyogenes)

AI-generated summary

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. At St John of God Midland Hospital on 23 August, a pulled elbow was suspected; when the child appeared to improve after X-ray manipulation, infection was excluded. At Princess Margaret Hospital ED the same day, despite fever, tachycardia, and a blanching rash, discharge occurred with parental consent. A GP visit on 24 August resulted in appropriate blood test orders but the family delayed testing. At Rockingham General Hospital on 25 August, septic shock was recognised and antibiotics given, but delayed senior consultation, inadequate fluid resuscitation, and communication gaps occurred. By PMH admission, Malakai had irreversible multi-organ failure despite maximal intensive care. The coroner found care 'understandable' given diagnostic difficulty and atypical presentation, though shortcomings at RGH were identified. Had sepsis been diagnosed one to two days earlier, outcome may have differed.

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

Specialties

emergency medicineintensive caregeneral practiceinfectious diseasesgeneral medicineradiology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

paracetamolibuprofenceftriaxone

Clinical conditions

sepsisseptic shockstreptococcal toxic shock syndromefulminant septicaemiameningococcaemiapurpura fulminansmulti-organ failureseptic arthritisosteomyelitispulled elbowbacteraemia

Procedures

X-ray imagingintravenous cannulation attemptsintraosseous accessintubation and mechanical ventilationextracorporeal membranous oxygenation (ECMO)

Contributing factors

  • Atypical presentation of deep-seated Streptococcus pyogenes infection in infant
  • Apparent clinical improvement after limb manipulation masking underlying infection
  • Difficulty distinguishing bacterial from viral illness in paediatric presentation
  • Lack of continuity of care across multiple health services
  • Delayed recognition of septic shock at Rockingham General Hospital
  • Delayed senior clinical consultation at Rockingham General Hospital
  • Inadequate fluid resuscitation at Rockingham General Hospital
  • Inadequate documentation of observations and care at triage and in emergency department
  • Limited access to cross-hospital medical records
  • Parental hesitancy regarding hospital admission despite clinical concerns

Coroner's recommendations

  1. Western Australian Department of Health should take steps to ensure clinicians in emergency departments have timely access to patients' health information from all sources across all hospitals
  2. Implementation of age-appropriate early warning tools such as PARROT charts (Paediatric Acute Recognition and Response Observation Tool) with emphasis on clinical assessment, clinician and family concern, escalation processes, and clinical communication
  3. Enhanced education and training regarding recognition and management of paediatric sepsis
  4. Improved documentation practices in emergency departments and triage areas
  5. Lower thresholds for escalation to senior clinicians in paediatric presentations
  6. Enhanced inter-hospital communication protocols for clinical handover
Full text
Official source Archived copy

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