Inquest into the death of Child MS

4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection

A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral upper respiratory tract infection. He was discharged with paracetamol and advice to return if symptoms worsened. Over the next 4 days, he deteriorated with persistent fever, loss of appetite, body aches, and poor sleep despite symptomatic treatment at home. He was found unresponsive on 14 September and died. Autopsy revealed Haemophilus influenzae septicaemia with respiratory tract infection and bilateral pleural effusions. The NT Health review identified that vital signs fell outside normal ranges (meeting ATS category 3), repeat vitals were not documented before discharge, and age-appropriate vital sign charts were not used—which might have prompted senior review. While the initial diagnosis of viral illness was reasonable, improved recognition of sepsis risk factors and repeat vital sign documentation could have enhanced safety netting and parental education.