Inquest into the death of Esteban FRANCO-GARCES

11y · Male·Sepsis

An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures included: delayed triage (20-minute wait), failure to involve senior staff early despite recognising sepsis in a high-risk neonate, multiple unsuccessful cannulation attempts without timely escalation to intraosseous or intramuscular administration, and communication breakdown (junior registrar unaware of critical blood gas results showing acidosis and elevated lactate). The coroner found this delay in treatment was not appropriate and did not give the child the best chance of survival. Significant system improvements have since been implemented including sepsis pathways, rapid response protocols, bedside handover, and electronic health records.