Inquest into the Death of Maarouf El-Cheikh
Deceased
Maarouf El-Cheikh
Demographics
57y, male
Date of death
2016-03-22
Finding date
2023-01-30
Cause of death
streptococcus pneumonia septicaemia due to splenectomy
AI-generated summary
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadequate urine output monitoring (no urinary catheter despite critical illness and acute kidney injury); delayed and sub-optimal antibiotic dosing and timing; failure to place arterial line for continuous blood pressure monitoring; and critically, failure to admit to ICU despite severe sepsis with lactic acidosis, hypotension (<90mmHg systolic for 3 hours), and MEWS scores >9. While the coroner found treatment sub-optimal and not giving Mr El-Cheikh a real chance of survival, systemic rather than individual clinician failures were identified: inadequate sepsis protocols, restricted access to infectious diseases specialists, poor escalation culture, and insufficient overnight medical staffing. The coroner made no individual criticisms but identified matters of public safety requiring hospital-wide improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to admit to ICU despite severe sepsis and clinical deterioration
- inadequate urine output monitoring
- delayed and sub-optimal antibiotic dosing
- delayed antibiotic administration
- failure to place arterial line for continuous monitoring
- hypotension remaining below 90mmHg systolic for 3 hours without escalation
- inadequate sepsis treatment protocols
- restricted access to infectious diseases consultation
- poor escalation culture and communication
- inadequate medical staffing on overnight shifts
- high ED workload (163 presentations on day of admission)
- history of splenectomy not adequately considered in risk assessment
Coroner's recommendations
- Implementation of updated sepsis protocol reflecting international guidelines
- Establishment of sepsis champion team
- Implementation of Australian Commission for Safety and Quality Sepsis Clinical Care Standard
- Enhancement of nursing training in sepsis care
- Random auditing of records to monitor compliance with sepsis protocols and antibiotic timing/dosing
- Bedside audits of sepsis protocol implementation including catheterisation, fluid balance monitoring and timely antibiotic administration
- Increase availability of onsite infectious diseases expert
- Empower Nursing Clinical Manager to call Emergency Consultant for care escalation
- Implementation of 'Speak Up for Safety' program to encourage staff to raise care concerns
- Improve monitoring processes with Nursing Clinical Manager rounds each shift
- Implementation of Digital Health Record with in-built sepsis tool
- Increase overnight medical staffing from 4 to 5 doctors
- Ensure emergency consultant always on-call overnight
Full text
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