Deputy state coroner Stephanie Gallagher has found that six-year-old Connor Dean died from scurvy, a condition once common among sailors and convicts, after a cardiac arrest under general anaesthetic at Queensland Children’s Hospital in 2024.
Connor, from Brisbane, was admitted to the hospital on 18 July 2024, after his parents reported knee pain and limping. X-rays and MRIs failed to show a clear cause. He then developed a cough, tested positive for parainfluenza, and his oxygen levels and kidney function worsened. He suffered a cardiac arrest after being given general anaesthetic and died on 10 August.
Coroner’s findings on cause of death
In findings released last month, Gallagher ruled that Connor’s fatal brain damage was most likely triggered by vitamin C deficiency and scurvy. “Although the precise mechanism leading to the cardiac arrest could not be definitively determined, the treating clinicians and forensic pathologist considered vitamin C deficiency to be the most likely underlying factor,” she determined.
Scans of Connor’s skeleton later showed bone changes “in keeping with scurvy”. Blood tests revealed a vitamin C level of less than one micromole per litre, compared with a normal range of 20 to 120 micromoles per litre. He was also low in vitamins A and E, had borderline low vitamin D, and had blood-clotting problems that suggested vitamin K deficiency.
Dietary concerns and multivitamin issues
Connor had Down syndrome, was born with a serious heart defect repaired in 2018, and had delayed development, speaking mostly in single words and walking with a wide-based gait. His paediatrician told the court that he and dieticians had long-standing concerns about the boy’s growth, with his height and weight well below the usual range, even for children with Down syndrome.
“He was reported to have become very fussy with his intake and his diet was said to contain no fruit or vegetables at that time,” the paediatrician said. “He had only gained 300 grams in the last 11 months.”
Connor was prescribed multivitamins. However, during his final admission, doctors found the multivitamin the family was using, known in the findings only as “the Product”, did not contain vitamin C.
Coroner focuses on failure to detect deficiency
The paediatrician expressed concern about the availability of the Product in Australia. “I am concerned that a product such as (the Product) is available in Australia. I believe that it is misleading to call this product a multivitamin when it misses essential vitamins such as Vitamin C,” he said. “It is my clinical opinion that Connor would not have had vitamin C deficiency, and the clinical features of scurvy that led to his death, if he had been taking a different multivitamin that contained vitamin C.”
The multivitamin’s manufacturer offered “sincere condolences” but rejected the paediatrician’s criticism, stating there was “no basis on which to draw the conclusion that [its multivitamin] has contributed to Connor’s death”. The coroner agreed there was not enough evidence to say the multivitamin caused or contributed to the death. Instead, she focused on the failure to detect Connor’s severe vitamin C deficiency in time.
