A six-year-old boy with Down syndrome died from a disease so rare it has not been prevalent in Australia for the last two centuries.
Queensland deputy state coroner Stephanie Gallagher has handed down her non-inquest findings into Connor Dean’s tragic death two years ago.
Connor lost his fight for life in Brisbane‘s Queensland Children’s Hospital on August 10, 2024 following complications related to scurvy, also known as ‘sailor’s disease’.
Scurvy is caused by a vitamin C deficiency and is most associated with sailors from the Renaissance and early modern period who could go for months without access to fresh fruit or vegetables.
It is now extremely rare in developed nations due to the wide availability of fresh produce. Mild cases are usually easily treated by including vitamin C in the diet but the disease can be fatal if untreated.
Professor Gallagher hoped that making her findings public will prevent similar deaths in the future.
Connor was born in 2018 with Down syndrome and a heart defect that required surgery.
He had slow developmental progress, while his communication was limited to mostly single words.
Six-year-old Connor Dean lost his fight for life in Brisbane’s Queensland Children’s Hospital in August 2024 following complications related to scurvy
A month before his death, Connor’s parents took him to a GP for knee pain, a shuffling gait and limping – initially thought to be from a playground fall.
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 para-influenza, his health was rapidly deteriorating and at one point, had to be resuscitated after he suffered a cardiac arrest.
In late July 2024, his parents were told that their son likely 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 from hypoxic ischaemic encephalopathy, a heart condition caused by a cardiac arrest likely brought on by vitamin C deficiency causing scurvy.
Connor was partially fed by a gastric tube until age two. His parents told the coroner he ate a variety of foods, including fresh produce, until he became a ‘very fussy’ eater at four-and-a-half.
‘Each said that they were not aware he had a Vitamin C deficiency until after his arrest,’ the coroner’s findings noted.
Mild cases are usually easily treated by incorporating vitamin C into the diet. Pictured is a fruit stall in Sydney
The findings also reported Connor’s pediatrician’s longstanding concerns about the boy’s weight and height.
‘His diet was said to contain no fruit or vegetables at that time. He had only gained 300g in 11 months (against the normal range of 1.5-2kg),’ the paediatrician told the coroner.
‘I told his mother that I was very concerned about Connor’s diet, specifically that it did not contain enough calories or the vitamins and minerals he needed to grow and be healthy.
‘I referred Connor to the dietitian and requested his parents commence a multivitamin.’
The paediatrician expressed further concerns about Connor’s diet at 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 being offered vegetables at day care but I don’t believe he was eating them.
‘He was drinking apple and blackcurrant 100 per cent juice poppers which would contain Vitamin C.’
Vitamin C is in a wide range of fresh produce, including oranges
The doctor said the multivitamin Connor was taking contained ‘small amounts’ of vitamin C but wasn’t the supplement he had recommended.
‘Given this uncertainty and the apparent lack of monitoring of Connor’s Vitamin C deficiency prior to his arrest, there is no basis on which to draw the conclusion that the product has contributed to Connor’s death,’ Professor Gallagher wrote.
She ruled that no further coronial inquiry or inquest was required.
‘I am of the view that, publishing these findings may be sufficient mechanism to draw attention to this death so as to prevent deaths in similar circumstances happening in the future,’ Professor Gallagher concluded.
‘I extend my condolences to Connor’s family and loved ones for their loss.’
