Finding into death of Lachlan Black

2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococcal infection and streptococcal toxic shock syndrome)

A 2-year-7-month-old boy died of Group A Streptococcal septicaemia after three presentations to hospital over three days. Clinical staff failed to recognise the developing bacterial infection despite objective warning signs. Key failures included: not escalating care when presented with persistent tachycardia (HR 180) on the third visit; failure to repeat vital signs within one hour to confirm the tachycardia; failure to examine and reassess after petechial rash appeared; and not taking baseline blood pressure until 8pm. Although antibiotics were eventually ordered at 8.30pm, there was a two-hour delay before administration. Had care been escalated when tachycardia was first identified, blood tests obtained by 2-4:30pm, and antibiotics given within 30-60 minutes, survival rates for invasive streptococcal infection are 90-95%. The coroner found shortfalls constituted departure from reasonable standard of care caused by human error and system failures.