Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was discharged with a viral diagnosis. He re-presented on 15 June appearing critically unwell but was triaged by an incompletely trained nurse who failed to obtain vital signs. He waited 3 hours for medical review while his condition deteriorated. Critical missed opportunities occurred during triage assessment and waiting period. Earlier vital signs and thorough assessment would likely have prompted timely sepsis recognition and treatment, optimising survival chances. Contributing factors included understaffing (untrained triage nurse, insufficient nursing coverage), inadequate medical staffing overnight (single registrar), lack of appropriate waiting area due to COVID-19, and unclear escalation policies.