A six-year-old boy with Down syndrome died from a disease so rare it has not occurred in Australia for two centuries.
Queensland Deputy Coroner Stephanie Gallagher has released her non-investigative findings into the tragic death of Connor Dean two years ago.
Connor lost his fight for life Brisbane‘s Queensland Children’s Hospital on August 10, 2024 after complications related to scurvy, also known as ‘sailor’s disease’.
Scurvy is caused by a deficiency of vitamin C and is most associated with sailors of the Renaissance and early modern periods who did not have access to fresh fruits or vegetables for months.
It is now extremely rare in developed countries due to the wide availability of fresh produce. Mild cases can usually be easily treated by including vitamin C in the diet, but the disease can be fatal if left untreated.
Professor Gallagher hoped her findings would be made public will prevent similar deaths in the future.
Connor was born in 2018 with Down syndrome and a heart defect that required surgery.
He experienced slow development, while his communication was limited to mainly a few words.
Six-year-old Connor Dean lost his fight for life at Queensland Children’s Hospital in Brisbane in August 2024 after complications related to scurvy
A month before his death, Connor’s parents took him to a GP because of knee pain, shuffling and limping – initially thought to be the result of a fall on the playground.
When his condition did not improve, he was admitted to Queensland Children’s Hospital for x-rays and an MRI scan.
By the time Connor was diagnosed with parainfluenza, his health was rapidly declining and at one point required resuscitation after going into cardiac arrest.
At the end of July 2024, his parents were told that their son probably had severe life-threatening scurvy. His life support was turned off on August 7 and Connor died three days later.
The death certificate concluded that Connor died of hypoxic ischemic encephalopathy, a heart condition caused by cardiac arrest that is likely caused by a vitamin C deficiency that causes scurvy.
Connor was partially fed through a gastric tube until the age of two. His parents told the coroner he ate a variety of foods, including fresh produce, until he became a “very picky” eater at the age of four and a half.
“Everyone said they were not aware he had a vitamin C deficiency until after his arrest,” the coroner’s findings said.
Mild cases can usually be easily treated by including vitamin C in the diet. Pictured is a fruit stand in Sydney
The findings also reported long-standing concerns of Connor’s pediatrician about the boy’s weight and height.
‘It was said that his diet at the time did not include any fruits or vegetables. He had gained only 300 grams (against the normal range of 1.5 to 2 kg) in eleven months,” the pediatrician told the coroner.
‘I told his mother that I was very concerned about Connor’s diet, specifically that it did not provide enough calories or the vitamins and minerals he needed to grow and be healthy.
‘I referred Connor to the dietitian and asked his parents to start a multivitamin.’
The pediatrician raised further concerns about Connor’s diet during a follow-up consultation six months later, in November 2023.
“His diet was still very poor with lots of white bread, some beef sausage, custard and chocolate,” he noted.
‘He was offered vegetables at daycare, but I don’t think he ate them.
‘He drank apple and blackcurrant poppers, 100 per cent juice, which contained vitamin C.’
Vitamin C is found in a wide range of fresh produce, including oranges
The doctor said the multivitamin Connor was taking contained “small amounts” of vitamin C, but was not the supplement he recommended.
“Given this uncertainty and the apparent lack of monitoring of Connor’s vitamin C deficiency prior to his arrest, there is no basis for concluding that the product contributed to Connor’s death,” Professor Gallagher wrote.
She ruled that no further coronial or inquest was necessary.
“I believe that publishing these findings could be a sufficient mechanism to draw attention to this death and thus prevent deaths under similar circumstances in the future,” Professor Gallagher concluded.
“I extend my condolences to Connor’s family and loved ones for their loss.”
