Six-year-old boy with Down syndrome died from scurvy due to undetected vitamin C deficiency, coroner finds

A six-year-old boy died from scurvy, the so‑called “sailor’s disease” common in the convict era, a coroner has found.

Brisbane boy Connor Dean died after a cardiac arrest under general anaesthetic at Queensland Children’s hospital in 2024.

Deputy state coroner Stephanie Gallagher released her findings last month, ruling his 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.

Issues with an unnamed multivitamin were also canvassed in the inquest.

Scurvy was once common among sailors and convicts who went without fresh fruit and vegetables on long sea voyages.

However, it is now so rare in Australia that serious cases are almost always found and treated.

Connor had Down syndrome, was born with a serious heart defect that was repaired in 2018, and had delayed development, speaking mostly in single words and walking with a wide‑based gait.

In July 2024, he went to his GP, with his parents reporting he had knee pain and was limping.

He was admitted to Queensland Children’s hospital on 18 July, with X‑rays and MRIs failing to show a clear cause.

He then developed a bad cough and tested positive for parainfluenza as his oxygen levels and kidney function worsened.

He suffered a cardiac arrest after being given general anaesthetic and died on 10 August.

Scans of his skeleton later showed bone changes “in keeping with scurvy”.

Blood tests revealed a vitamin C level of less than 1 micromole a litre, compared with a normal range of 20 to 120 micromoles a litre.

He was also low in vitamins A and E, had borderline low vitamin D and blood‑clotting problems that suggested vitamin K (potassium) deficiency.

His paediatrician told the court he and dieticians had longstanding 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.

“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,” the paediatrician 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 and said 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.