Finding into death of Makayla Lee Wadeson

9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl with pulmonary thromboembolism and deep vein thrombosis

Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and discharged with a diagnosis of otitis externa after a 40-minute wait. Critical clinical lessons: her elevated heart rate (146 bpm) at triage was not recognised as abnormal, she should have been triaged Category 3, her immunosuppressed status was not documented in the ED record despite being on immunosuppressants for ulcerative colitis, and no repeat observations were performed despite policy requirements. She deteriorated at home and died two days later from pneumonia caused by Streptococcus pneumoniae and Candida albicans with concurrent pulmonary thromboembolism and DVT. The coroner identified that recognition of her abnormal vital signs and appropriate escalation of observations may have prevented her death through earlier detection of systemic illness.