Inquest into the death of Zena Stevens

2y · Female·septicaemia

Zena Stevens, a 2.5-year-old Aboriginal girl, died from septicemia at Tennant Creek Hospital on 14 January 2005. She had presented to clinic on 11 January with fever, purulent ears and a recently lanced abscess after recent discharge from hospital without review or discharge medications. Clinic nursing staff and the District Medical Officer agreed she should be evacuated to hospital, but this decision was reversed after the District Medical Officer deferred to the Hospital Medical Superintendent's judgment based on 'normal' observations and a 'wait and see' approach. The child deteriorated over subsequent days and was eventually transported by ambulance (taking 3+ hours over dirt roads) and arrived in extremis, requiring ventilation. The senior paediatrician concluded she should have been evacuated on 11 January. Poor communication between District Medical Officer and Hospital Medical Superintendent, inadequate documentation review, and lack of clinical escalation contributed to the 2-day delay in appropriate transfer. Additionally, police failed to properly record and investigate the reportable death, allowing an inappropriate death certificate to be issued.