A coroner’s report has revealed that Monash Health breached Monash Health reasonable care. This omission led to the unnecessary death of toddler Dio Kemp from sepsis in November 2019. Dio’s coroner, Spanos, went on record saying Dio’s treatment was inadequate. This shocking announcement renewed calls for improved health care to better serve the needs of children with specialized needs.
For her teenage son Dio Kemp – who has Down syndrome – that meant frequent trips to the Monash Medical Centre in Melbourne’s south-east. Her mother, Miranda Jowet, took her on these repeated journeys. During that period, from November 23 to November 29, 2019, Jowet escorted Dio to five different doctor visits. This involved up to four visits to their local GP practice. After first showing symptoms of diarrhoea and general rash, his health rapidly began to decline, with high fever and gripping crying. Unfortunately, just three days before her sudden death, Dio contracted sepsis.
A Series of Unanswered Cries for Help
Miranda Jowet was passionate in her deep frustration about the medical care delivered to her daughter. She remembered feeling a complete sense of hopelessness as she walked through those hospitals. The Jowet is mad as hell. She continues to believe that medical staff members dismissed her desperate requests and placed no importance on her daughter Dio’s worsening health.
“I urge doctors to set aside assumptions and truly listen to parents.” – Miranda Jowet
The coroner’s findings have alarmingly called into question the treatment protocols and practices at Monash Health. Coroner Spanos also reiterated that Dio Kemp did not receive proper medical treatment. Given her clinical picture and diagnosis, her lack of treatment was a huge injustice. This tragic incident underscores an important point. It underlines the importance of improving communication between clinical staff and parents, especially those who look after children with intellectual disabilities.
In 2017, a coronial inquest had previously recommended that Monash Health implement policies to re-evaluate patients returning to the emergency department within 72 hours. It seems that these recommendations have not been properly implemented in real-world practice.
A Growing Concern for Pediatric Care
Dio Kemp’s case isn’t a one-off. Another child, Lachlan Black, recently died from sepsis after arriving at the same emergency department 12 minutes before Oliver. These events have raised questions about the adequacy of pediatric emergency care protocols at Monash Health. We require an overhaul of the systems at play to properly do so.
Family advocate Paul Oliver spoke to the dangers of ignoring parents—especially in medical settings. He made the case that parents have a deep, intuitive knowledge of their children’s well-being long before clinical signs are present.
“Parents know when our kids are unwell. We know instinctively long before any clinical markers become present.” – Paul Oliver
For Oliver, the critical element to achieve a cultural change in pediatric emergency medicine at Monash Health is cultural leadership. Until that happens, countless other children will be at risk of suffering the same fate.
The Call for Improved Training and Awareness
Miranda Jowet and the Kemp family are advocating for change following this tragic case. They’re calling on health services to do better in training medical staff on sepsis. They argue that the onus must be on healthcare providers to effectively communicate with parents to provide their patients’ safety and well-being.
Jowet recalled the harrowing experience of watching her daughter’s condition worsen and ultimately succumb to illness, stating, “I watched Dio die in front of me, and my son and I will never forget the desperate attempts to resuscitate her tiny body.”
Here in Dickson, the Kemp family wishes for others to avoid a similar tragedy and understand that sepsis can have such drastic effects. Healthcare systems need to be part of the solution to advance health equity. This is critical for all of our children, but especially so for our special needs children, who need more individualized attention.
