Inquest into the Death of Child MD (Name Subject to a Suppression Order)
Deceased
Child MD
Demographics
2y, male
Coroner
Coroner Urquhart
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. Report an inaccuracy.
intubationmechanical ventilationpercutaneous endoscopic gastrostomy (PEG) insertioncataract surgerymyringotomy and grommet insertionbilateral orchidopexyorthopaedic surgery for vertical talus
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
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.