A 10-year-old girl who died after contracting the herpes simplex virus - which most notably causes the common cold sore - suffered from a lack of “continuous” medical care, an inquest has found.
Five doctors failed to diagnose Briony Klingberg, after she became feverish and unwell at her Adelaide Hills home in January 2015.
She died of multiple organ failure in the Women’s and Children’s hospital just days later.
Coroner Mark Johns said “no single medical professional” had an opportunity to observe the progress of the girl’s illness and her deteriorating condition.
“It’s easy to say in retrospect that continuity of care would have been highly desirable,” he revealed.
After she became unwell, Briony’s mother, Bridget Kingberg took her to the Women’s and Children’s Hospital where doctors detected an ulcer on her throat, but she was sent home soon after.
“She and her husband had the sense that they should not come back unless Briony got worse,” the coroner said.
The next day Briony was taken to see a different doctor at Mount Barker Hospital. But Mr Johns revealed that had she returned to the Women’s and Children’s hospital instead, a comparison of her condition from the day before could have been made.
“Such a comparison would likely have raised concerns and prompted further investigations.”
Mr Johns also revealed that Briony’s general practitioner – who was the final doctor to see her – failed to take observations of the girl during a consultation. He said the doctor took delivery of significant blood results by phone without writing them down and failed to immediately inform the girl’s mother that she should be taken to hospital.
“In saying these things I acknowledge the evidence that by then it would, in all likelihood, have been too late to save Briony’s life,” he said.
“Nevertheless, it is a matter of serious concern that he did not act appropriately as he should have done.”
When Briony finally returned to hospital, she collapsed in the carpark outside the emergency department before being taken to intensive care where she died the next day.
The Herpes virus was not detected until after her death.
The coroner has made it clear that Briony’s parents were not to blame for her death in anyway, but urged parents to see the same doctor when their children are ill.
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