Inquest into the death of Amanda Dana TAUAI

21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)

Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote Paraburdoo Hospital was appropriate, but critical clinical deterioration occurred 10pm on 14 March when her blood pressure declined significantly. Dr M. was not notified of this critical observation. When contacted at 2:05am on 15 March about ongoing vomiting, he initially managed her as hypovolemic shock with fluids and dopamine. Broad-spectrum antibiotics were not administered in Paraburdoo because Dr M. believed the presentation was viral, not bacterial. Full blood picture results showing elevated neutrophils (suggesting bacterial infection) were not available until after transfer. Expert review suggests earlier blood cultures and empirical antibiotics at 3am on 15 March (after vital sign abnormalities documented) may have improved outcomes, though this remains uncertain. Key failures included failure to escalate a critical 10pm blood pressure reading and delayed diagnostic results typical of remote settings.