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Queensland coroner finds six-year-old boy died from scurvy

A coronial inquest found severe vitamin C deficiency caused by a restrictive diet was the most likely trigger for fatal brain damage following cardiac arrest.

The short version

  • Six-year-old Connor Dean died in August 2024 at Queensland Children's Hospital after suffering cardiac arrest while under general anaesthesia.
  • Coroner Stephanie Gallagher ruled that the fatal brain damage was most likely triggered by severe vitamin C deficiency and scurvy arising from an extremely restrictive diet.
  • Although medical staff raised concerns over a commercial multivitamin product used by the family that lacked vitamin C, the coroner found insufficient evidence to conclude the supplement contributed to the death.

Key facts

  • Connor Dean, a six-year-old with Down syndrome and a history of a surgically repaired heart defect, died on August 10, 2024, after experiencing cardiac arrest under general anaesthesia.[The Guardian]
  • Post-admission blood testing showed Connor's vitamin C levels were under 1 micromole per litre, compared to the normal reference range of 20 to 120 micromoles per litre.[The Guardian]
  • Connor's paediatrician reported that the child had an extremely restrictive diet with no fruit or vegetables and had gained only 300 grams across an 11-month period.[The Guardian]
  • Deputy State Coroner Stephanie Gallagher determined that while the precise mechanism for the cardiac arrest could not be definitively established, vitamin C deficiency was the most likely underlying factor.[The Guardian]
  • The coroner found insufficient evidence to determine that the family's multivitamin product caused or contributed to the death, despite paediatrician criticism of the product omitting vitamin C.[The Guardian]

What remains uncertain

  • The exact physiological mechanism that triggered the cardiac arrest under anaesthesia could not be definitively determined by clinicians or the forensic pathologist.[The Guardian]

Sources