Finding into death of Master S

13y · Male·Asthma

Master S was a 13-year-old Aboriginal boy with severe persistent asthma who died at home on 13 November 2019. He was found unresponsive with his nebuliser mask on his face. The coroner accepted that death resulted from asthma. Expert review confirmed his asthma management was appropriate and consistent with Australian guidelines, with exemplary care from treating clinicians including A/Prof Roseby and the urgent care centre. However, a critical gap was identified: treating clinicians lacked real-time access to PBS dispensing data showing Master S was collecting far fewer preventer medications than prescribed, suggesting poor medication adherence. Had clinicians known this objectively, they could have implemented targeted adherence interventions. The finding highlights that medication compliance monitoring remains unrealised within SafeScript, which currently monitors only controlled drugs, not essential preventer medications.