A boy died of scurvy — his multivitamin had no vitamin C

What just happened

A coroner has found that a 6-year-old boy, Connor Dean, who had trisomy 21 — Down syndrome — died from scurvy after his family followed medical advice to give him a multivitamin. The supplement they purchased contained iron. It contained no vitamin C.

Scurvy. A disease most Australian clinicians associate with maritime history and Victorian-era poverty. A child died of it in 2026.

Connor’s eating had become severely restricted from around age five. His diet consisted mainly of white bread, sausages, chocolate, and custard — foods with virtually no vitamin C content. In May 2023, his paediatrician noted he had gained only 300 grams over the preceding 11 months. Blood tests revealed deficiencies in iron, vitamin B12, vitamin A, and vitamin D. The advice was to start a multivitamin. His family did exactly that.

The supplement they were effectively directed to contained iron. It did not contain vitamin C.

The treating paediatrician subsequently criticised how a product with iron could be registered and sold in Australia without vitamin C — particularly given that vitamin C is required for adequate non-haem iron absorption. A supplement combining iron with no ascorbic acid is not just incomplete — it may be less effective at correcting the co-existing iron deficiency it was presumably intended to treat.

Connor died of scurvy-related complications.

Both-and

How Australia’s supplement framework creates this risk

The Therapeutic Goods Administration registers complementary medicines — including vitamins and multivitamins — under two main pathways. Listed medicines (AUST L) are evaluated for safety and quality, and labelling is audited for accuracy. What is not mandated is that any product calling itself a “multivitamin” contain any particular minimum set of nutrients. The label “multivitamin” is a category claim, not a nutritional guarantee.

This creates a genuine information gap. A GP who recommends “a good multivitamin” is relying on the implicit assumption that a product sold as such in a reputable pharmacy will contain the full complement of essential micronutrients. Most do. Some do not.

The paediatrician in this case criticised the supplement’s composition. But the gap the coroner’s finding exposes is not simply a bad product — it is a mismatch between clinical language (“get a multivitamin”) and what patients and families actually hear (“any multivitamin will do”). In a child whose diet is severely restricted and who is deficient in multiple nutrients, that mismatch is dangerous.

The population this most concerns

Children with Down syndrome have substantially elevated rates of food selectivity, oral hypersensitivity, and dietary restriction — features that overlap considerably with those seen in autism spectrum disorder. These are children whose unusual eating patterns are often known to their clinical team, yet the nutritional monitoring that should accompany them can be inconsistent or absent.

GPs and paediatricians often reach for a supplement recommendation as a safety net when dietary variety is limited. That instinct reflects good clinical reasoning. But it only protects the patient if the supplement actually contains the nutrients the child is lacking.

Vitamin C is water-soluble, cheap, and physiologically uncontroversial. There is no clinical reason to omit it from a product marketed as a multivitamin. Yet in this case it was absent — and the absence went undetected until too late.

What GPs can do differently

The change in practice this coroner’s finding calls for is not complicated. Before recommending any supplement to a patient with restricted eating, food selectivity, or suspected micronutrient deficiency, specify the nutrients you want covered — not the product category. “A supplement containing vitamin C, vitamin D3, and iron” gives the family clear information to act on. “A multivitamin” does not.

If you have the product in front of you at the consultation or can access its consumer medicine information, check it. The TGA’s ingredient declaration requirements mean the label must list what is present — but it does not flag what is missing by design.

Vitamin C deficiency is uncommon enough in the general Australian population that it rarely features in routine adult health assessment. It is not rare enough to ignore in children with severe food selectivity, and it is not harmless in prolonged deficiency states. Dietary intake requirements for Australians are set by the NHMRC at 45 mg/day for adults, with higher targets in pregnancy — levels that are easily met by one piece of fruit but not met at all by a diet of white bread and sausages.

2 cents

Three things for general practice this week:

Name the nutrient, not the category. When a patient or their family is directed to supplement for a known deficiency, the clinical instruction should specify the nutrient. “Get vitamin C” cannot be circumvented by a mislabelled product. “Get a multivitamin” can.

Children with intellectual disability or ASD on restricted diets are a distinct risk group. Their dietary limitations are not always communicated across clinicians, and micronutrient deficiencies in this population deserve active surveillance — not just a reassuring supplement recommendation.

AUST L means the TGA has assessed safety, not nutritional completeness. That is worth explaining when a patient or parent asks whether a supplement is “regulated” or “safe.” It is assessed for safety. It is not guaranteed to be nutritionally adequate for any specific clinical need.

Verdict: yes — worth knowing about. A coroner’s finding from a real case, with a practice change that takes 30 seconds.

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Sources cited

1. Boy died of scurvy after taking multivitamin that contained no vitamin C, coroner finds. Australian Doctor, 8 September 2026.