Coronial
NSWhospital

Inquest into the death of Peter SMITH

Deceased

Peter Smith

Demographics

67y, male

Date of death

2018-02-06

Finding date

2019-10-25

Cause of death

Gas gangrene with antecedent cause of Clostridium septicum septicaemia

AI-generated summary

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and died from gas gangrene caused by Clostridium septicum. While the coroner found no material deficiencies in clinical care, the underlying infection was extraordinarily atypical and had extremely high mortality (>60%) regardless of management. A critical system failure identified was unavailability of blood gas cartridges when needed—only one iStat cartridge remained in stock. The coroner found that even had blood gas testing been performed, prognosis would not have changed. Expert consensus confirmed this rare infection was likely fatal before hospital arrival, but the case highlighted gaps in supply inventory systems in regional hospitals.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicinegeneral practiceintensive careinfectious diseasesmicrobiology

Error types

system

Drugs involved

morphineketorolacfentanylparacetamolibuprofendiazepamflucloxacillingentamycinpenicillinadrenalinenoradrenaline

Clinical conditions

clostridium septicum septicaemiagas gangrenenecrotising fasciitisrhabdomyolysisseptic shockmuscle breakdownacute kidney injury

Procedures

venous blood gas testingblood transfusionintubationcardiopulmonary resuscitation

Contributing factors

  • Clostridium septicum infection—atypical, fulminant presentation without typical sepsis indicators
  • Unavailability of CG4+ blood gas cartridges for diagnostic testing
  • Inadequate supply inventory systems in regional hospital
  • Rare clinical presentation without fever, hypotension, or other classic sepsis markers
  • Rapidly progressive necrotising infection with minimal time for diagnosis or intervention

Coroner's recommendations

  1. New South Wales Health should review its supply and inventory systems in District hospitals to ensure that stocks of all necessary diagnostic and medical supplies are maintained at levels sufficient to meet anticipated need
  2. The review should consider whether existing systems are vulnerable to error and introduce where necessary clear guidelines around monitoring stock levels, prescribed trigger points for reordering, and periodical audits of stock and supply systems to ensure compliance with adequate stock levels
Full text
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Source and disclaimer

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