Overview

• Dio Kemp, 3, died of bacterial septicaemia in 2019 after four emergency department visits and two GP appointments over eight days.
• The coroner found care during her final presentations was not reasonable, citing failures by an ED clinician, a rapid review doctor, and a GP.
• Evidence indicated a group A streptococcal infection by November 26 to 28, leaving a window when urgent tests and timely antibiotics might have averted death.
• Her mother urged clinicians to treat repeat presentations and parental concern as a red flag and to prioritise non‑verbal children with intellectual disabilities.
• Monash Health said it will review the findings following its internal changes, as the court signalled publication of full findings and called for audited implementation and sepsis training.