LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral upper respiratory tract infection symptoms and chronic impetigo. Although GP management was deemed appropriate by independent review, critical delays occurred at the hospital: delayed recognition of septic shock, delayed intravenous access (three hours), delayed antibiotics and fluid resuscitation, and delayed retrieval initiation. The child deteriorated acutely with petechial haemorrhages and shock, ultimately developing bilateral cerebral infarction despite intensive care. Key lessons include implementing paediatric early warning tools (CEWT), sepsis pathways, intraosseous access protocols when IV access fails, and senior-led retrieval for critically unwell children. Early recognition and rapid intervention could have optimised care, though outcome uncertainty remains.