Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus pyogenes)

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. At St John of God Midland Hospital on 23 August, a pulled elbow was suspected; when the child appeared to improve after X-ray manipulation, infection was excluded. At Princess Margaret Hospital ED the same day, despite fever, tachycardia, and a blanching rash, discharge occurred with parental consent. A GP visit on 24 August resulted in appropriate blood test orders but the family delayed testing. At Rockingham General Hospital on 25 August, septic shock was recognised and antibiotics given, but delayed senior consultation, inadequate fluid resuscitation, and communication gaps occurred. By PMH admission, Malakai had irreversible multi-organ failure despite maximal intensive care. The coroner found care 'understandable' given diagnostic difficulty and atypical presentation, though shortcomings at RGH were identified. Had sepsis been diagnosed one to two days earlier, outcome may have differed.