Coroner's Finding: JOHNSON Olivia Jean

0y · Female·dehydration

Olivia Johnson, an 11-month-old Indigenous infant, died of dehydration from acute gastroenteritis in a remote location. She presented to Leigh Creek Medical Clinic with 48 hours of vomiting and diarrhoea and was likely already hypernatraemically dehydrated, but was discharged home after examination by Dr C. who concluded she showed no signs of dehydration. Dr C. performed inadequate history-taking, did not establish the true frequency of fluid losses (at least 8 nappy changes), and dismissed the mother's concerning observations about sunken/dark eyes. He failed to consider hypernatraemic dehydration where skin turgor testing is unreliable. Critically, he did not account for the patient's 2-hour remote location when making discharge decisions. Olivia deteriorated rapidly at home and died that evening despite CPR by her parents. The coroner found her death was preventable—admission to hospital would likely have enabled diagnosis, treatment, and if needed, retrieval to higher care.