Boy, 6, died from hidden scurvy after multivitamin lacked vitamin C

A six-year-old boy died from cardiac arrest linked to the “sailor’s disease” scurvy, after a hidden vitamin C deficiency triggered a collapse following a routine MRI, a coroner has found.

Connor Dean, who had Down syndrome and complex medical needs, died at Queensland Children’s Hospital after suffering a cardiac arrest in July 2024.

In non-inquest findings released last week, Deputy State Coroner Stephanie Gallagher found severe vitamin C deficiency was the key underlying factor in his death.

Connor had long been under specialist care and had already overcome major health challenges, including surgery as a baby to repair a serious heart defect.

But by 2023, concern was growing about his nutrition as his eating became more restricted.

“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 findings quoted the pediatrician.

The court was told Connor was referred to a dietitian and his family was advised to start him on a multivitamin.

“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,” the pediatrician said.

“I referred Connor to the dietitian and requested his parents commence a multivitamin.’’

Doctors later believed those nutritional needs were being covered.

“I discussed with Connor’s mother that Connor’s diet was inadequate to meet his vitamin and mineral requirements, but that I believed that we were covering these requirements with the multivitamin, Vitamin D3, Ferroliquid and vitamin A injection.”

“I (also) encouraged Connor’s mother to give Connor one 100 per cent juice popper every day.’’

In July 2024, Connor was taken to hospital after weeks of leg pain and refusing to put weight on his legs.

Doctors were investigating possible causes including infection, injury or cancer.

On July 20, he underwent an MRI under general anaesthetic.

The scan was completed, but Connor deteriorated in recovery and suffered a cardiac arrest. Although doctors restored circulation after several minutes, he suffered devastating brain injury and died on 10 August 2024.

His formal cause of death was listed as hypoxic-ischaemic encephalopathy, cardiac arrest after general anaesthetic, vitamin C deficiency and Down syndrome.

During the investigation, it emerged the over-the-counter product he had been taking did not contain vitamin C. The findings also noted it lacked vitamins K and E.

That missing vitamin proved crucial. Tests showed Connor’s vitamin C level was less than 1, well below the healthy range of 20 to 120.

He also showed classic signs of scurvy, including tiny haemorrhages on his body and changes seen on MRI scans.

The coroner accepted evidence from treating doctors and the forensic pathologist that vitamin C deficiency was the most likely underlying cause of the cardiac arrest.

The findings noted rare cases in medical literature where children with scurvy develop pulmonary hypertension and can arrest during sedation or anaesthesia.

The case also exposed a dispute over what parents can reasonably expect from a product labelled a multivitamin, with Connor’s pediatrician raising concerns that the product he had been given did not contain vitamin C.

“I believe that it is misleading to call this product a multivitamin when it misses essential vitamins such as vitamin C,” the pediatrician said.

“It is my clinical opinion that Connor would not have had vitamin C deficiency, and the clinical features of scurvy that lead to his death, if he had been taking a different multivitamin that contained vitamin C.”

The manufacturer defended the label in a statement to Ms Gallagher, arguing the term multivitamin was “well understood to mean multiple nutrients’’.

However the products “do not generally contain all essential vitamins and nor are they indicated for treatment of a severe deficiency’’.

Despite that concern, Ms Gallagher found there was not enough evidence to conclude the supplement itself contributed directly to Connor’s death because there had been an “apparent lack of monitoring of Connor’s vitamin C deficiency prior to his (cardiac) arrest’’.

Even so, the findings make clear the deficiency had gone unnoticed until it was too late.

The coroner closed the matter without an inquest, finding the circumstances had been adequately investigated.

“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,” Ms Gallagher said.