Mother’s Plea After Sepsis Death: Doctors Must Listen to Parents
Following a coroner’s inquest, Miranda Jowett is urging medical professionals to prioritize parental concerns and thoroughly investigate illnesses in children, notably those with disabilities. Her daughter, Dio Kemp, died from sepsis in November 2019 after multiple visits to doctors and a hospital failed to identify teh severity of her condition.
Ms. Jowett took Dio, a non-verbal toddler with Down syndrome, to Monash Medical Centre four times and a family GP twice, presenting with a rash and fever. on each occasion, medical professionals attributed Dio’s symptoms to a virus or fever, recommending pain medication and observation.
The Victorian Deputy State Coroner, Paresa Spanos, found that better investigation of Dio’s symptoms in the three days leading up to her death could have saved her life.The coroner’s report detailed that a GP, along with two clinicians at Monash Medical Centre – one in the emergency department and another in a rapid review clinic – did not provide care meeting current standards.
Specifically,the emergency department clinician failed to consider a potential bacterial infection and did not adhere to Monash Health guidelines. The coroner noted this clinician also did not adequately respond to Ms. Jowett’s expressed concerns about her daughter’s condition, failing to escalate monitoring or investigation. the rapid review clinic doctor was criticized for not fully considering Dio’s clinical picture after five days of fever, deeming a planned GP review in two days insufficient without clearer guidance. The GP’s care on November 26 and 28 was also found to be below reasonable standards.
While the exact time a bacterial infection would have become detectable remains undetermined, the coroner concluded there was a period within the final three days of Dio’s life where intervention could have potentially prevented her death, requiring thorough examination, recognition of possible infection, urgent testing, and timely treatment.
Monash Health has already undertaken a review and implemented changes to its care guidelines following Dio’s death. Ms. Jowett’s lawyer, Samuel Pearce, welcomed these changes but stressed the need for “rigorous training and cultural change” to prevent similar tragedies.
Dio’s uncle, Paul oliver, echoed this sentiment, imploring Monash Health to prioritize listening to parents, emphasizing that Ms.Jowett “knew instinctively” the seriousness of Dio’s illness. He warned that without a shift in the culture of pediatric emergency medicine at Monash, further preventable deaths could occur.
Monash Health stated it will review the coroner’s findings and consider any recommendations to improve patient care.
