Coroner's Finding: PARROTT Jenisha Diandra (aka White)

7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess

A 7-week-old infant died from streptococcus pneumoniae sepsis complicating retropharyngeal abscess. Three days before death, a report was made to child protection services alleging the father had shaken the infants. A general practitioner with no child abuse training examined both children and found no obvious injuries. Critically, X-rays were not performed despite allegations of shaking; these would have revealed rib and leg fractures, confirming abuse and triggering immediate referral to tertiary paediatric services with specialist child protection expertise. The fatal abscess would likely have been detected and treated with antibiotics, preventing death. Key failures were: no strategy discussion involving specialist child protection services before examination, lack of radiological imaging, and absence of education about shaken baby syndrome signs and investigations among rural medical practitioners.