Coroner attributes child's death to severe vitamin C deficiency and possible scurvy in Down syndrome case

A coroner has linked the death of six-year-old Connor Dean, who had Down syndrome and complex medical needs, to severe vitamin C deficiency and suspected scurvy, raising concerns over nutritional monitoring in vulnerable children.

Connor Dean, a six-year-old boy with Down syndrome and complex medical needs, died at Queensland Children’s Hospital after a cardiac arrest that a coroner linked to severe vitamin C deficiency and likely scurvy. Deputy State Coroner Stephanie Gallagher found that the deficiency was the key underlying factor after Connor collapsed following a routine MRI under general anaesthetic in July 2024. The findings say his death was formally attributed to hypoxic-ischaemic encephalopathy, cardiac arrest after general anaesthetic, vitamin C deficiency and Down syndrome.

The coroner heard that Connor had been under specialist care for years and had already survived major health problems, including surgery as a baby to repair a serious heart defect. But by 2023, doctors were increasingly worried about his diet, which had become highly restricted and reportedly contained no fruit or vegetables. A paediatrician told the court Connor had gained only 300g in 11 months, far below the expected range, and said the family was advised to start a multivitamin after concerns that he was not getting enough calories or micronutrients to grow properly.

In July 2024, Connor was admitted to hospital after weeks of leg pain and refusing to bear weight. Doctors considered infection, injury and cancer before he underwent the MRI. Although the scan was completed, he deteriorated in recovery, suffered a cardiac arrest and, after circulation was restored, developed catastrophic brain injury. The court heard that his vitamin C level was less than 1, compared with a healthy range of 20 to 120, and that he showed classic signs of scurvy, including tiny haemorrhages and changes on MRI.

The case also exposed confusion over the supplement Connor had been given. According to the findings, the over-the-counter product did not contain vitamin C and also lacked vitamins K and E. Connor’s paediatrician told the coroner it was misleading to describe the product as a multivitamin if it omitted essential vitamins, while the manufacturer said the term was commonly understood to mean multiple nutrients and that such products were not designed to treat a severe deficiency. Gallagher did not conclude the supplement directly caused the death, but said the deficiency had apparently not been monitored closely enough before the arrest. She closed the matter without an inquest, saying the published findings should help prevent a similar death. Medical literature cited in the findings notes that scurvy can, in rare cases, lead to serious cardiovascular complications, including pulmonary hypertension and arrest during sedation or anaesthesia.