Inquest into the Death of Child MD (Name Subject to a Suppression Order)
Deceased
Child MD
Demographics
2y, male
Date of death
2021-05-12
Finding date
2023-11-17
Cause of death
multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndrome
AI-generated summary
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poor oral intake. He was admitted to Perth Children's Hospital paediatric ICU after initial presentation to a regional hospital. The coroner found that emergency department management was appropriate, including antibiotic selection (single agent ceftriaxone per guideline) and decision not to escalate to consultant—neither impacted outcome. A medication error occurred where acetylcysteine was given intravenously instead of by nebulisation on two occasions, but this was determined to be safe. The child received quality, compassionate medical care from dedicated staff. The child had been in appropriate Department care since birth following pre-birth planning due to maternal risk factors. A minor system issue regarding acetylcysteine formulation packaging was subsequently corrected to prevent recurrence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Cockayne syndrome—a rare life-limiting genetic disorder affecting DNA repair mechanisms leading to progressive organ dysfunction
- clinically suspected sepsis with mixed bacterial and fungal infection
- acute liver failure
- acute kidney injury
- severe respiratory failure
- coagulopathy
- underlying hepatic dysfunction pre-existing in Cockayne syndrome
- fungal infection of left kidney (Candida tropicalis)
- middle ear effusions with bacterial and fungal elements
Coroner's recommendations
- Continuation of revised dispensing procedures at Perth Children's Hospital regarding acetylcysteine nebulised formulation to prevent further incidences of intravenous administration error
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