Coroner's Finding: MARTIN Kirsten Lee

24y · Female·multi organ failure due to meningococcal septicaemia

24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis through absence of neck stiffness and rash. She diagnosed viral illness with possible urinary tract infection and discharged her after 3 hours. Parents were given reassurance rather than clear warning signs. Patient deteriorated at home, presented 5 hours later with characteristic petechial rash, admitted to ICU, but died within hours from meningococcal septicaemia. Critical failures: over-reliance on absence of rash and meningeal signs to exclude meningococcaemia; failure to seek senior review before discharge despite uncertainty; inadequate communication with parents about red flags. Early admission for observation and consideration of empiric antibiotics when clinical suspicion existed could potentially have altered outcome.