Overview

• Deputy State Coroner Paresa Spanos concluded three-year-old Dio Kemp’s death from bacterial septicaemia could potentially have been prevented in the final three days of her life.
• Dio was taken to Monash Medical Centre four times and to a GP twice over eight days for fever and a rash before she died on November 29, 2019.
• The coroner found an ED clinician and a rapid review clinic doctor at Monash provided care that was not reasonable by current standards, and a GP’s management on November 26 and 28 also fell short.
• Monash Health said it will review the findings, noting it previously updated care guidelines after an internal review, as the court encouraged audits of those changes.
• Outside court, Dio’s mother urged that repeated parental presentations be treated as a red flag and called for a right to immediate independent ED review, highlighting the heightened risks for non-verbal children with disabilities.