Coroner's Finding: Beltz, Sarah Rose

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Sarah Rose Beltz Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Sarah Rose Beltz; b) Miss Beltz died as a result of contracting Neisseria meningitidis; c) The cause of Miss Beltz’s death was bacterial sepsis (septic shock); and d) Miss Beltz died on 12 July 2018 at the Department of Emergency Medicine, Royal Hobart Hospital, Hobart in Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Miss Beltz’s death. The evidence comprises an opinion of the forensic pathologist who conducted the autopsy; relevant police and witness affidavits; and medical records and reports.

Sarah, cherished daughter of Nicholas and Belinda, lover of horses and friend to many, died within a matter of hours of contracting Neisseria meningitidis or, as it is more commonly known, meningococcal disease.

At the time of her death Sarah was a student at St Mary’s College in Hobart.

Meningococcal immunisations for strains A, C, W and Y were administered at that school on 27 March 2018. Miss Beltz was absent from school that day and thus did not receive that immunisation. Had she then undoubtedly it would have saved her life.

Once she fell ill everything that could be done for Sarah was done. Her father rushed her to Hobart Private Hospital as soon as it was clear that her symptoms were serious.

Staff at the Hobart Private realised straight away that Sarah should be treated at the Royal Hobart Hospital and she was immediately transferred to that Hospital’s Department of Emergency Medicine (DEM).

As soon as she arrived at the DEM Sarah was immediately assessed and treatment commenced straight away. However, nothing could be done for Sarah and she passed away within a very short time.

Given the nature of her sudden and unexpected death, the fact of her passing was reported under the provisions of the Coroners Act 1995. After formal identification Sarah’s body was transferred to the mortuary at the Royal Hobart Hospital. At the Hospital mortuary an autopsy was carried out by experienced forensic pathologist, Dr Donald McGillivray Ritchey. Dr Ritchey expressed the opinion that the cause of Sarah’s death was bacterial sepsis. He described sepsis as a “dreaded complication of…[Meningococcal] where the bacteria enter the blood causing overwhelming immunologic and biochemical disruption resulting in death by a mechanism of septic shock”. I accept Dr Ritchey’s opinion.

Comments and Recommendations Part of the role of a coroner investigating any death is to make recommendations in appropriate cases “with respect to ways of preventing further deaths” (see section 28(2) of the Coroners Act 1995). The tragic circumstances of Sarah’s death lead me to conclude that it is appropriate in this instance to make recommendations with a view to preventing deaths in the future, if possible, from meningococcal.

Meningococcal disease is caused by bacteria (not by a virus), and is transmitted via mucus. Meningococcal bacteria can (and do) live harmlessly in the human throat and nose. Around 20 percent of people will be carrying these bacteria at any one time without ever becoming ill. In fact, many people will carry the bacteria at some stage in their lives.

There are many different strains of meningococcal disease. In Tasmania the most common strains are A, C, W, Y and B. The W strain has caused the majority of cases in Tasmania in recent years.

Relatively speaking, meningococcal disease is uncommon in Tasmania. But people, especially young people, who develop it can become extremely unwell and die in a very short period of time.

An additional complicating factor is that the symptoms of meningococcal disease are often very difficult to distinguish from the common flu.

The best protection against meningococcal, indeed virtually the only protection, is immunisation.

In Tasmania free immunisation is available for any person born after 1 August 1997 against strains A, C, W and Y. This programme was implemented by the Department of Health and Human Services after Sarah’s death. It replaced a programme of free vaccination against W strain only.

The introduction of the programme and the widespread advertising and information that accompanied its introduction is to be commended.

I recommend pursuant to Section 28 of the Coroners Act 1995 that every eligible person avail themselves of the free immunisation service.

I note that presently meningococcal B vaccine is not available free of charge but is available on private prescription.

I recommend that the current free immunisation programme be extended to include the meningococcal B vaccine.

I convey my sincere and respectful condolences to the family and loved ones of Miss Sarah Rose Beltz.

Dated 19 February 2019 at Hobart, Tasmania.

Simon Cooper Coroner