Inquest into the death of Michaela Perrin
Deceased
Michaela Perrin
Demographics
26y, female
Date of death
2014-10-22
Finding date
2018-02-27
Cause of death
sepsis
AI-generated summary
Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and fever. Dr P., the obstetrics registrar, conducted an inadequate assessment without reviewing notes, palpating the abdomen, or taking vital signs, and discharged her with analgesia alone. When Michaela returned on 21 October with obvious signs of sepsis (fever 39.3°C, severe pain, abdominal swelling), Dr P. finally recognised possible infection but kept this assessment undisclosed. Although antibiotics were eventually commenced, critical failures included: absent documentation, failure to take cultures until late, absence of IV fluids despite ordering them, poor handover to night staff, inadequate ward observations, and lack of recognition of sepsis severity. The coroner found her death was potentially avoidable with timely sepsis recognition, immediate admission, blood cultures, inflammatory markers, imaging, empirical antibiotics and IV fluids on day 1.
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 recognise sepsis on initial presentation
- grossly inadequate history taking and physical examination
- failure to take vital signs on 20 October 2014
- failure to order investigations on 20 October 2014
- failure to document clinical findings
- failure to admit patient for observation on 20 October 2014
- failure to communicate severity of condition to consultant
- failure to communicate severity to night shift staff
- failure to recognise earlier skin infections as potential warning signs
- no swabs taken at earlier presentations with skin infections
- lack of knowledge of sepsis recognition and management
- failure to initialise IV fluids on 21 October despite ordering them
- inadequate handover to night staff
- inadequate patient observations on ward (4-hourly instead of hourly)
- patient placed in inadequate setting (ward instead of HDU)
- junior midwife caring for deteriorating patient without adequate support or training
- inadequate training on maternal sepsis pathway
Coroner's recommendations
- Consideration should be given to using Michaela's story of rapid deterioration from maternal sepsis as a case study for educating midwives and other staff at the Lismore Base Hospital Maternity Unit
- A copy of these findings should be forwarded to the Health Care Complaints Commission (HCCC) so that consideration may be given to an investigation of Dr P.'s clinical conduct
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