Finding into death of Noah Andrew Souvatzis

1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain swelling, patchy cerebritis with secondary haemorrhage, and cerebellar tonsillar herniation necrosis

Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation included: a junior, inadequately oriented locum (Dr B.) misdiagnosing bacterial meningitis as viral gastroenteritis; failure to recognise severe illness despite tachycardia, tachypnoea, lethargy, and inability to tolerate oral fluids; inappropriate discharge after failed oral rehydration attempt; and lack of senior clinician review before discharge. Verbal handover information about need for IV fluids and paediatric review was not communicated to Dr B.. Parents' escalation concerns were not addressed through any formalised system. Had RCH Febrile Child guidelines been followed or senior clinician examined Noah, early antibiotics and admission would likely have prevented his death. The coroner found the death was preventable and made recommendations regarding parental concerns as vital signs.