MESYUARAT TEKNIKAL KEMATIAN

PENYAKIT BERJANGKIT

PATIENT NAME :
IC NO:

1
SECTION 1: CASE
Place of Death Hospital XX
(name of hospital/clinic)
Type of Death CDC/Dengue/Malaria/TB Mortality

Date of Admission 07/03/2018

(dd/mm/yyyy)

Date of Death 07/03/2018

(dd/mm/yyyy)

Date of Notification XX/XX/2018

(dd/mm/yyyy)

2
SECTION 2: PATIENT DETAILS
Patient Name
XX

IC/RN XXXXXX-XX-XXXX

Residence
SEGAM BATU 8, DEKAT PERTANIAN VOKASIONAL, BELAKANG KEDAI
RUNCIT ROSTIKA, LAHAD DATU

Ethnicity DUSUN

Gender MALE

Occupation

3
SECTION 4: PATIENT’S DEATH DETAILS
Date of birth:
31/12/2017 Age at death: XX-years-old
(dd/mm/yyyy)
Patient’s Health Clinic/GP: Date & time of
NIL 07/03/2018 7.13PM
(name of clinic) death :

History of presenting illness

Presented to ED 19/2/18 1615H

-status epilepticus x 1/7 – generalized tonic clonic seizure, 18 minutes, aborted spontaneously in
ED
-fever x 1/7
-cough x 1/52- not prolonged, no facial congestion, frothy oral secretion
-vomiting x 1/52- once per day

No passing loose stool

No runny nose
No sick contact
SECTION 4: PATIENT’S DEATH DETAILS

Upon arrival at ETD :

o/e: encephalopathic , irritable, lethargic looking, tachypnic with moderate subcostal

recession, CRT< 2 sec, good pulse volume, warm peripheries, immediate skin turgor, oral
thrush

BP: 75/54 mmHg (MAP: 58)

HR: 189 bpm
T: 36.9 C
SPO2 under RA: 90% 100% under HFM O2 10L/min
DXT: 5.4mmol/L
SECTION 4: PATIENT’S DEATH DETAILS
CVS. S1S2, soft systolic murmur.
Lungs : bilateral crepitation
Abdomen : soft, not distended, hepatomegaly with liver 1cm palpable
CNS: neck stiffness, generalized hypertonia and hyperreflexia

Ultrasound brain (bedside) :

Investigations (19/2/18):
Blood 19/2/18 CXR Bilateral pneumonic
gas changes
pH 7.438

pCO2 47.3

pO2 29.5

HCO3 31.3

BE 57.6
 CXR 19/2/18

22/1/26
SECTION 4: PATIENT’S DEATH DETAILS

Impression :
1. Meningitis with severe pneumonia in compensated shock
SECTION 4: PATIENT’S DEATH DETAILS
In ED,
-child was put on headbox 10L/min
-given IV NS 10cc/kg
-started on
IV C-Penicillin 100000u/kg/dose stat
IV Cefotaxime 75mg/kg/dose stat
IM ATT 0.5ml stat
IM TIG 250u stat
IM vitamin K 1mg stat
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
19/2/18 Event Management

2130H Arrival in SCN Decided for intubation for airway protection

noted persistent tachycardia,
grunting, deep chest recession Ventilation- moderate setting

Given IV NS 10cc/kg x2

Loaded with IV phenobarbitone

IV C-Penicillin 100000u/kg/dose QID

IV Cefotaxime 75mg/kg/dose QID
IV Dexamethasone 0.5mg QID
PO Nystatin 50000u QID
Noted blood stain on suction IV Omeprazole 1mg/kg BD
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
20/2/18 Event Management

0100H Noted child has persistent
tachycardia with hypotension
1115H Haemodynamically stable
Started on low dose Ivi Adrenaline
Child was ventilated under moderate setting
ventilation
Off Ivi Adrenaline
weaning down ventilator setting

LP done- suggestive meningitis To complete IV C-penicillin and IV Cefotaxime

for 14 days
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
21/2/18 Event Management

Hypotension and tachycardia Weaning down ventilator setting

resolved

Fighting over ventilator Increase the dose of sedations- Ivi

Midazolam and Ivi Morphine
22/2/18 Event Management

0800H Unable to wean down Repeated CXR: improving lung field.

ventilator to lower setting
overnight
1020H Tachycardia with stable BP IV NS bolus 10cc/kg x 2
poor perfusion Echo done by paeds specialist: IVC not
collpsible, normal heart structure and IJC
normal
Increase to full maintaince
restarted Ivi Adrenaline low dose

IMP: ?undervolume
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
22/2/18 Event Management

1445H Noted FBC worsening Transfuse packed cell 10cc/kg

Hb: 24.4- 11.6 Escalated antibiotic to IV Meropenam
Twbc: 21.2 29
PLT: 568 378

Repeated CXR: not worsening

preliminary Blood C&S report noted:

Gram Negative Rod

1900H Child was tachycardia, poor perfusion, Need higher ventilator settings
BP stable Given IV bolus NS 10cc/kg x 2
Passed loose stool x 3 times

K: 2.6 Started on mist KCL 500mg BD

(repeated on 23/3: 3.7)
2335H Noted lip smacking, uprolling of Loaded with IV phenobarbitone and
eyeballs maintaince dose
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
FBC 22/2/18 BUSE/Creatinine 22/2/18 LFT 22/2/18
HB 11.6 Na 134.9 T.Bilirubin 14
TWC 29 K 2.6 D.Bilirubin 6
NEU 63.2% ALT 23
Urea 2.5
LYMP 22.7%
Creat 11 T.Protein 41
PLT 378
Cl 86 Albumin 24
HCT 34.1%
ALP 71

Blood gas 22/2/18 6am 22/2/18 8AM 22/2/18 3PM 22/2/18 10PM

pH 7.468 7.497 7.507 7.466

pCO2 51 39.8 39.4 35.4

pO2 46.9 77.7 98.2 95.9

HCO3 36.1 30.1 30.5 24.9

BE 12.4 6.9 7.5 1.2

SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
FBC 23/2/18 BUSE/Creat 23/2/18 Blood gas 23/2/18 7AM 23/2/18 1PM 23/2/18 6PM 24/2/18 12MN

Na 136 pH 7.53 7.405 7.480 7.522

HB 15.4
K 3.7
pCO2 31 57 37.4 21.4
HCT 43.6 Urea 2.6
Creat - pO2 60.3 44.3 52 44.7
TWC 29.8
Cl 90 HCO3 25.3 34.9 27.2 17.2
Calcium 2.05
NEU 68.4 BE 2.6 10.2 3.7 -5.7
LYMP 1 PO4 0.99

PLT 337 Mg 0.81

CK 98.24
LDH 559
Albumin 29
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
25/2/18 Event Management

0000H ETT dislodged. Desaturation Reintubated with high ventilator setting

down to 55%. Repeated CXR: no new changes

2000H good urine output & able to wean off IVI Dobutamine
haemodynamically stable

2100H full blood C&S report available : antibiotic shifted to IV Ceftriaxone

Salmonella sp. 50mg/kg/dose BD
-sensitive to Ceftriaxone
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient

Blood 24/2/18 24/2/18 24/2/18 25/2/18 25/2/18 25/2/18 25/2/18 25/2/18 26/2/18
gas 6AM 12MD 6PM 12MN 2.30AM 7AM 1PM 7PM 12MN

pH 7.510 7.474 7.604 7.595 7.645 7.461 7.564 7.528 7.43

pCO2 38.3 40.3 19.4 11 10.7 17.6 27.2 37.1 43.2

pO2 117.5 48.2 139.5 177.4 178.3 165.9 123 153.5 94.6

HCO3 29.9 28.9 18.8 10.4 11.3 12.2 24 30.2 26.1

BE 6.9 5.3 -2.7 -11.2 -9.5 -11.6 1.9 7.4 3.8

SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
26/2/18 Event Management

1445H Case discussed with paediatric ID team -Continue IV Ceftriaxone and to complete at
least 3 weeks course & for weekly LFT
monitoring
-Add on IV Amikacin for 1 week course
-No need to repeat lumbar puncture in view
that CSF C&S no growth
-To notify case (although not Salmonella typhi
but this is invasive Salmonella sp disease)
-For CRP monitoring weekly
-For US Brain 3 weeks after IV antibiotic
Continue head circumference monitoring

26/2-3/3/18 Event Management

Able to wean down ventilator setting blood C&S on 26/2/2018 preliminary report :
further Gram Positive Cocci
Able to wean down sedation -blood C&S repeated and added IV
haemodynamically stable unsupported Vancomycin 10mg/kg/dose QID
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
4/3/18 Event Management

0945H Child desaturated down to 87% Increased to higher setting of

under moderate ventilator settings, ventilation-moderate setting
tachypnic with chest recession

Repeated CXR: not improving

1100H Repeated FBC Transfused 10cc/kg PC

Hb: 10.5
Twbc: 12.3
PLT: 64

2045H Noted persistent passing loose NBM with IVD full maintainance 
stool improved
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
FBC 4/3/18 BUSE 4/3/18 Blood 4/3/18 4/3/18 4/3/18 4/3/18 5/3/18
gas 6AM 8AM 12PM 6PM 12MN
HB 10.5 Na 125 pH 7.422 7.496 7.46 7.377 7.391

HCT 30.5 K 3.1

pCO2 55.6 41.2 36.7 53.8 36.9

TWC 12.3 Ur 3.8

pO2 58.8 78.6 106.2 78.2 132.3

NEU 48 Creat 16
HCO3 35.5 31.1 25.5 30.9 21.9
LYMP 37.9
Cl 83
PLT 64 BE 11 7.8 1.7 5.7 -3
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
7/3/18 Event
1315H Persistent hypotension, poor
perfusion
DXT 0.8mmol/L  1. 3
RT aspiration: fresh blood
FBC noted Hb 10, platelet 19
K: 7.4 (lyzed) repeated 7.2
1450H Persistent hypotension,
hypoglycemia, coagulopathy and
thrombocytopenia
1700H K post lytic cocktail: 6.8
Management
To transfuse
PC 10cc/kg
FFP 10cc/kg
Platelet 10cc/kg
Given IV D10 bolus 5cc/kg
Changed IVD to D10
IV Omeprazole 3.5mg stat and TDS
Given lytic cocktail x 1
Another bolus IV D10 5cc/kg
Plan to transfuse another cycle of DIVC
regime with 20cc/kg each component
Given Neb salbutamol x2
Given lytic cocktail x 1
supp kalimate 2g QID
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
7/3/18 Event
1940H Child was desaturated and
bradycardia with 3 maximum dose
of inotropes
Pronounced death on 7/3/18
1913H
Cause of death: invasive Samonella
species sepsis with meningitis and
new onset sepsis
Management
CPR commended total 30min
IV Calcium gluconate x3
IV NaHCO3 x 3
IV adrenaline 0.1mg/kg x 15
IV NS bolus 20cc/kg x 1
IV platelet 20cc/kg
IV FFP 10cc/kg
post-mortem lumbar puncture done ->
high pressure
CSF: blood stained
intracardiac blood C&S taken under
aseptic technique
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
FBC 7/3/18 7/3/18 Coag profile 7/3/18 7/3/18 BUSE 7/3/18 7/3/18 7/3/18 7/3/18

HB 10.8 10 Na 127.5 - - -
PT 23.9 20.9
HCT 34 28.8 K 5.2 7.4 7.2 6.8
PTT >120 123.8 (lyzed) LC x1 LC x2
TWC 4.9 5.1
Ur 12.8 - - -
NEU 49.9 41 INR 2.04 1.78
LYMP 1 2.5 Creat 66 - - -

PLT 1 19

Blood gas 7/3/18 7/3/18 7/3/18 7/3/18

5am 8am 12md 6pm

pH 7.04 7.029 7.178 7.269

pCO2 63.4 86.8 70.7 49

pO2 89 61.5 58 67.8

HCO3 13.5 22.4 25.7 22

BE -14.5 -8.5 -2.7 -5

SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
Invstigations Date Date Result
taken resulted
Blood C&S 19/2/18 25/2/18 Salmonella sp sent for serotyping

Sensitive :
Chloramphenicol
Ampicillin
Ciprofloxacin
Ceftriaxone
Trimetophrim Sulphamethoxazole

Serotyping 27/3/18 Samonella Weltevreden

Tracheal asp C&S 19/2/18 22/2/18 No growth

Blood C&S 22/2/18 1/3/18 No growth

Stool C&S 22/2/18 24/2/18 Salmonella/Shigella not isolated
Stool FEME 23/2/18 23/2/18 Mucous – negative;
Ova/Cyst of Hokworm/Ascaris
lumbricoides/Trichuris trichura/E.Histolytica -
negative
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
Blood investigation
Investigations Date Date Results
taken resulted

TSH 24/2/18 4/3/18 1.99IU/mL

FT4 16.50pmol/L

Blood C&S 26/2/18 3/3/18 Micrococcus sp – Suspected contamination

CRP 26/2/18 10/3/18 50.4mg/L

Tracheal asp C&S 27/2/18 1/3/18 No growth

Stool C&S 28/2/18 1/3/18 Salmonella/Shigella not isolated

Blood C&S 3/3/18 9/3/18 No growth

Stool C&S 5/3/18 6/3/18 Salmonella/Shigella not isolated

CRP 5/3/18 13/3/18 88.5mg/L

SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
Blood investigation
Investigations Date Date Results
taken resulted
Blood C&S 6/3/18 13/3/18 Klebsiella ornithinolytica

Sensitive :
Amikacin
Trimethoprim-Sulfamethoxazole
Meropenam
Imipenam
Cefoxitin
Ertapenam

Resistant :
Ampicillin
Cefoperazone
Cefuroxime
Gentamicin
Amoxycillin-Clavulanic acid
Ceftazidime
Ceftriaxone
Ciprofloxacin
Cefepime
Cefotaxime
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
Investigations Date Date Result
taken resulted

Urine C&S 6/3/18 8/3/18 No growth

PBF 7/3/18 12/3/18 HB :9.4, TWC : 5.6, PLT : 5

RBC : Normocytic normochromic; occasional
polychromasia; No Nrbc seen.
WBC : reduce; no blast cell seen.
Platelet : markedly decreased (0-1/hpf); no platelet
clump seen.
Blood C&S 7/3/18 17/3/18 Stenotrophomonas maltophilia
(intracardiac) Sensitive : Trimetoprim-Sulfamethoxazole

CSF C&S 7/3/18 10/3/18 No growth

(post mortem)

CSF FEME 7/3/18 - Unable to proceed as blood stained

CSF Glucose 7/3/18 8/3/18 8.9mmol/L
CSF Protein 7/3/18 8/3/18 7.31g/L
CSF Latex 7/3/18 8/3/18 Cryptococcus – negative
Agglutination No reagent for H.Influenza B/S.Pneumoniae.Group
SECTION 4: PATIENT’S DEATH DETAILS
Progress of patient
Date Antibiotic Duration

19-22/2 IV C-penicillin 3 days

19-22/2 IV cefotaxime 3 days

5/3-6/3 (2 doses)
22-25/2 (TDS dose) IV meropenem 6 days
6-7/3 (BD dose)
25/2- 5/3 IV ceftriaxone 8 days
26/2- 4/3 IV Amikacin 7 days
4-5/3 IV vancomycin 2 days

6/3 IV cefepime 1 dose

6-7/3 IV clindamycin 2 days

SECTION 5: REMEDIAL FACTORS or SHORTFALL IN CASE
MANAGEMENT
Remedial clinical factors or shortfall in case management
contributing to death

Remedial non-clinical factors or shortfall in case management

contributing to death
SECTION 6: DECISION BY DISTRICT/HOSPITAL U-5 MORTALITY
MEETING
Is this death preventable?

If yes, specify & explain preventable factor(s)

Remedial action by district/hospital