Coroner Finds Missed opportunities in Death of Toddler, mother Pleads for Doctors to Heed Parental Instincts
Melbourne, Australia – A Victorian coroner has found that a series of missed opportunities in medical care likely contributed to the death of two-year-old Dio Jowett, prompting a grieving mother’s urgent plea for doctors to prioritize parental concerns when assessing sick children. Deputy State Coroner Paresa Spanos delivered the findings on Thursday, detailing failures in care provided by a GP and clinicians at Monash Health in the days leading up to Dio’s death.
The coroner’s report highlighted that better investigation of Dio’s symptoms over the three days prior to her passing “potentially” could have saved her life. Spanos found the care provided by a GP and two Monash clinicians was “not reasonable by current standards.” Specifically, an emergency department clinician and a rapid review clinic clinician, who both saw Dio between November 22nd and 23rd, failed to meet expected standards of care.
The ED clinician did not consider the possibility of a bacterial infection and did not adhere to Monash Health guidelines, while the rapid review clinic doctor did not adequately weigh Dio’s overall clinical picture, deeming a GP review in two days “not safe enough” without clear guidance.The GP’s management of Dio on November 26th and 28th was also deemed “not reasonable by current standards.”
“Many [children with intellectual disabilities] cannot communicate their symptoms like neurotypical children can and that makes them especially vulnerable,” a statement included in the report noted, underscoring the need for heightened sensitivity in such cases.
While the coroner could not pinpoint exactly when a bacterial infection would have become detectable, she concluded that “as a matter of logic there must have been a 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.”
Monash Health has already undertaken a review and implemented changes to its care guidelines following Dio’s death. However,outside court,Jowett’s lawyer,Samuel Pearce,emphasized the need for broader systemic change. “We welcome the findings from the coroner, and we welcome the changes that have been implemented since Dio’s death,” Pearce said. “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, echoed this sentiment, directly addressing Monash Health: “Unless the culture within pediatric emergency medicine starts to change at Monash, more children will die.” He stressed that Dio’s mother, Jowett, ”knew instinctively” how unwell her daughter was.
A Monash Health spokesperson stated the institution would review the coroner’s findings and “consider any learnings or recommendations to ensure our patients receive the best care possible.”
