Missed opportunities in fatal child abuse

摘要

A 3-month-old ex-full-term infant was transferred from an outside institution following cardiopulmonary arrest. Over the 3 weeks before admission, the parents report that the patient had upper respiratory symptoms, fever, irritability, and emesis. The patient was brought to an outside emergency department (ED) and to the primary care physician for a total of 9 times over the course of 22 days. On the final day of presentation, the father reported bilious emesis and lethargy. The patient was apneic upon arrival to the outside institution; cardiopulmonary resuscitation was initiated, and the patient was intubated.