A young girl whose family believes she was abandoned by Victoria’s healthcare system suffered from a particularly rare and deadly complication, a pediatric infectious disease doctor says.
The girl, who was given the alias Sasha at an inquest, died at Melbourne’s Royal Children’s Hospital in August 2019, after being admitted to Central Gippsland Health four days earlier.
An autopsy revealed that Sasha died of complications from influenza, pneumonia and blood poisoning, followed by heart and respiratory failure.
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Pediatric infectious disease physician and microbiologist Meryta May demonstrated that Sasha had a rare complication that presented itself in subtle and unusual ways.
The heart condition, called pneumococcal endocarditis, has a 20 percent mortality rate regardless of treatment, she told the Victorian Coroners Court on Tuesday.
Based on what the doctors documented, it wasn’t reasonable for anyone involved in Sasha’s care to initially diagnose her with the condition because there was little evidence as to what caused her illness, May said.
Even when she arrived at the Royal Children’s Hospital her condition was not clear – “she was really a diagnostic dilemma at that point” – and staff only found endocarditis after an echocardiogram.
May felt it might have been prudent for doctors to put Sasha on antibiotics as soon as she was admitted to Central Gippsland Health.
“She really was a diagnostic dilemma“
While it might have delayed Sasha’s demise, it wouldn’t have prevented her death, May suggested.
A doctor gave evidence that staff delayed giving Sasha antibiotics because it may have “masked” a surgical presentation and delayed diagnosis.
An abscess in Sasha’s heart practically destroyed part of her aortic valve and caused her heart to collapse.
The microbiologist suggested that medical staff should be better educated on how to recognize sepsis and that communication processes should be improved.
Sasha’s pathology results were faxed to Central Gippsland Health rather than called, so there was a delay of hours before medical staff saw her and she could have been monitored more closely at one stage.
The investigation was previously heard by Central Gippsland Health’s Executive Director of Quality and Learning, Kelli Mitchener, who agreed that the failure to share Sasha’s past outpatient records with inpatient staff represented a missed opportunity.
Boxes on a patient consent form were left unchecked and staff missed several opportunities during Sasha’s first 24 hours in the hospital to establish that she was subject to a child protection order.
Approval for Sasha’s medical procedures had to be granted by the Department of Family, Fairness and Housing under the order, the court said Monday.
Sasha’s mother claims to have told a Central Gippsland Health nurse that her daughter’s father had heart problems – information he believed could have made a difference in her care.
https://7news.com.au/politics/law-and-order/girl-12-who-died-weeks-after-returning-from-camp-was-diagnostic-dilemma-c-9076148 The 12-year-old girl, who died weeks after returning from the camp, presented a “diagnostic dilemma”.