Coroner's Court of Western Australia

Inquest into the death of Sebastian Keith PARMAN

Inquest into the Death of Sebastian Keith PARMAN

Delivered on:  20 May 2016

Delivered at:  Perth

Finding of:  Coroner King

Recommendations : Yes

That the Department of Health determine whether doctors in the public health system should employ the strategy of delayed prescriptions of antibiotics, and provide guidance accordingly.

That the Western Australian Country Health Service consider and, if practicable, implement a procedure to ensure that, where appropriate, radiologists’ reports of X-rays of children with potentially serious illnesses are provided to requesting clinicians with the least possible delay.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was six years old at the time of his death.  He had been exhibiting mild flu-like symptoms for the previous three or four days and had developed a bright red rash over his body.

On 14 September 2010 the deceased attended the emergency department at Geraldton Regional Hospital (GRH) with his father, a registered nurse who worked at the hospital.  A locum emergency doctor examined the deceased informally, so no documentation was created.  The deceased did not have a fever at the time.  The doctor concluded that the probably had a viral illness, but may have had scarlet fever or tonsillitis.  She prescribed oral penicillin to be administered if the deceased’s condition worsened.

The next day returned to GRH with a rash, a high temperature, a high heart rate and a moist cough.  He saw a different emergency doctor who thought that the deceased had a viral illness but ordered a chest X-ray to rule out pneumonia.   The doctor left work before the X-ray was taken, having arranged for the doctor from the previous day to check it.  After checking the X-ray, the locum doctor discharged the deceased into the care of his mother.

Overnight the deceased’s condition worsened.  The next day his mother took him to a GP who diagnosed the deceased with scarlet fever.  He went to GRH where a paediatrician diagnosed the deceased with scarlet fever and administered intravenous penicillin and maintenance fluids.  The deceased had extremely elevated heart rate and respiratory rate indicative of sepsis or septic shock, requiring boluses of fluids in addition to penicillin and maintenance fluids, but the paediatrician did not consider that the deceased was septic.  He died early the next morning.

The Coroner found that the deceased died from pneumonia complicating influenza (H1N1) infection and that death occurred by way of natural causes.

There were failures at different levels in the care and management of the deceased. Following the deceased’s death, many systemic improvements were implemented at GRH.

Catch Words :  Scarlet fever;  Influenza;  Swine Flu;  H1N1; Septic Shock; Delayed Radiology Results ; Informal Presentation; Delayed Prescriptions

Last updated: 30-Apr-2019

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