Objective: To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease. Design: Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases. Setting: National statistics and hospital records. Subjects: All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country. Main outcome measures: Predefined criteria defined optimal management. A panel of paediatricians blinded to the outcome assessed case records using a standardised form and scored patients for suboptimal management. Results: We identified 143 cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate analysis identified three factors independently associated with an increased risk of death: failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognise complications of the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002). The odds ratio for death was 8.7 (95%confidence interval 2.3 to 33) with two failures, increasing with multiple failures. Conclusions: Suboptimal health care delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses. Objective: To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease. Design: Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases. hospital records. Subjects: All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country. Main outcome measures: Predefined criteria defined optimal management. A panel of patients with blinded Results: optimal identified cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate identified three factors independently associated with an increased risk of death: failure to be look ed after by a pediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognize the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002 The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two failures, increasing with multiple failures. Conclusions: Suboptimal health care delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses.