Cubatão City Council Investigates Child's Death After Multiple ER Discharges

The Cubatão City Council in São Paulo, Brazil, has established a Special Inquiry Commission (CEI) to investigate the death of two-year-old Matteo Lima Albertino. The child passed away on June 30th at the Municipal Hospital, hours after being admitted to the Intensive Care Unit (ICU). His death followed multiple visits to the Municipal Emergency Room between June 27th and 29th, where he was reportedly treated and discharged three times without undergoing necessary examinations. The Legal Medical Institute (IML) has identified sepsis, a generalized infection, as the preliminary cause of death. The CEI will examine potential administrative, structural, operational, and care-related failures that may have contributed to the tragedy. It will also review medical and hospital protocols and the actions of responsible parties. The Municipal Health Secretariat is also conducting its own investigation, employing auditor physicians and nurses to review medical records and procedures. This internal probe includes the implementation of the London Protocol, a method for detailed investigation of adverse events and deaths. The Secretariat has requested reports from the Pediatric Emergency Room and the involved hospital, but has noted delays in receiving complete documentation, impacting the initial technical analysis timeline. The family alleges that Matteo presented with fever, vomiting, diarrhea, and an anal abscess, and that his condition worsened after receiving significant IV fluids. They claim medical staff were uncertain of the diagnosis and did not order initial imaging tests, with a CT scan only performed on the fourth day. The family also asserts there was a delay in securing an ICU bed, and Matteo was transferred to the Municipal Hospital in critical condition before his death.