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A Victorian toddler’s death could have been prevented if medical staff investigated her symptoms more thoroughly in the last three days of her life, a coroner has found.
Three-year-old Dio Kemp succumbed to bacterial septicaemia almost six years ago despite her mother taking her to one of Melbourne’s largest hospitals four times, and twice to see a family GP, in the days before her death. Bacterial septicaemia occurs when bacteria enters the bloodstream and causes blood poisoning.
Dio’s mother, Miranda Jowett, initially sought medical attention because she was concerned about her daughter’s fever and a bright rash on her cheek. The years-long inquest into Dio’s death previously heard that doctors believed she had a viral rather than a bacterial illness, and therefore couldn’t be treated with antibiotics.
Miranda Jowett, mother of Dio Kemp, reading a statement to the media outside the Victorian Coroners Court on Thursday.Credit: AAP/James Ross
Dio first became sick around November 19, 2019, and was taken to Monash Medical Centre’s emergency department two days later, on November 21.
The little girl died on November 29 after repeated visits to the hospital, through the emergency department and a rapid review clinic, and to a GP close to the family home in Melbourne’s south-east.
On Thursday, coroner Paresa Spanos found that the evidence suggested Dio’s initial illness – with its associated symptoms of diarrhoea and a rash – was caused by a viral infection.
Dio Kemp was adored by her family. She died in November 2019.
However, the coroner also found that Dio likely had a group A streptococcus infection – a type of bacterial infection – by November 26, and certainly had this condition by November 28.
While she could not determine the precise time at which the bacterial infection took hold, or would have been detectable by a thorough investigation, the coroner said it was “a matter of logic” that there would have been a period of time within the last three days of Dio’s life when there was “a potential” to prevent her death.
“This would have required competent examination by a GP or hospital clinician, recognition of the possibility of a bacterial infection, urgent investigations and the timely initiation of treatment,” Spanos told the court.
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“I wish to convey my sincere condolences to Dio’s parents. I also acknowledge the impact of Dio’s death on the clinical staff of Monash Health.”
Bacterial and viral infections can have similar symptoms but are treated differently. Blood and urine tests can help a doctor diagnose a bacterial infection, which can be treated with antibiotics.
The coroner noted that Monash had conducted an internal review since Dio’s death, but she encouraged the health service to audit its updated guidelines and processes.
Outside court, Jowett said she didn’t want to see another child suffer the way her daughter had.
“I watched Dio die in front of me and my son, and I will never forget the desperate attempt to resuscitate her tiny body,” Jowett said.
“I can only dream of her and imagine a life where she’s still alive. Parents must not be afraid to speak up and question a diagnosis when they’re concerned. I urge parents of very sick children to ask, ‘Could this be bacterial?’ or ‘Could this be sepsis?’ I urge doctors to set aside assumptions and truly listen to patients.”
Dio’s mother also called for children with an intellectual disability to be given the highest priority in emergency care.
“Many cannot communicate their symptoms like neurotypical children can, and that makes them especially vulnerable.”
Dio, who had Down syndrome, was non-verbal and had developmental delays. She could crawl and communicate some things, such as using a hand signal for water and wanting “more”.
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The family’s lawyer, Samuel Pearce from Maurice Blackburn, said it was not the first time his firm had represented clients who had lost a child in circumstances where their concerns were not seriously taken into account by a hospital.
“We welcome the changes that have been implemented since Dio’s death, but we urge that those changes be accompanied by rigorous training and cultural change to ensure that this does not happen to another family.”
Dio’s uncle, Paul Oliver, also standing outside court to support his sister-in-law, paid tribute to other children who had died from septicemia – including two-year-old Lachlan Black, who died at the Monash Medical Centre in August 2014 after seeing six medical practitioners over four days.
A spokesperson for Monash Health, which operates the Monash Medical Centre, described Dio’s death as a tragedy.
“We remain deeply saddened by the tragic death of Dio, and again offer our sincere condolences to her family and loved ones,” the spokesperson said.
“Monash Health will review the coroner’s findings and consider any learnings and recommendations to ensure our patients receive the best care possible.”
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