Coronial
NSWhospital

Inquest into the death of Maureen Smith

Deceased

Maureen Anne Smith

Demographics

75y, female

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2018-04-01

Finding date

2023-08-21

Cause of death

Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis

AI-generated summary

A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropriately identified possible septic arthritis and contacted orthopaedic registrar Dr N., who advised withholding antibiotics pending joint aspiration at Armidale Rural Referral Hospital. However, critical delays occurred: a non-emergency transport booking was made, then transferred to NSW Ambulance around 3.15pm. At 5.07pm, ambulance crew declined transfer citing resource constraints, advising the patient would go "tomorrow". Dr M. and nursing staff failed to adequately escalate or insist on urgent transfer. The patient remained at Glen Innes overnight without appropriate observations or antibiotics. On 1 April, increasing confusion was noted ("off with the fairies") but not recognised as sepsis marker. Transport was rebooked but delayed further. By arrival at ARRH at 3.14pm, the patient was in shock and died shortly after. Key failures: failure to recognise and escalate sepsis signs (delirium); inappropriate advice to withhold antibiotics once same-day transfer became impossible; breakdown in inter-hospital transfer coordination with excessive focus on "between-the-flags" status; and inadequate nursing observations overnight.

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

Specialties

orthopaedic surgeryemergency medicineinfectious diseasesgeneral medicine

Error types

diagnosticcommunicationsystemdelayprocedural

Drugs involved

corticosteroid injectionsmorphineparacetamolamitriptylineintravenous fluids

Clinical conditions

sepsisseptic arthritissepticaemiadeliriumacute kidney injurystaphylococcus aureus infectionshock

Procedures

joint aspiration (knee)corticosteroid injectionblood culture collectionpoint of care testingcardiopulmonary resuscitation

Contributing factors

  • Advice to withhold antibiotics when transfer delayed
  • Failure to recognise sepsis signs including delirium/confusion
  • Delays in inter-hospital transfer exceeding 24 hours
  • Breakdown in coordination between transport agencies
  • Inadequate nursing observations overnight
  • Disproportionate focus on "between the flags" vital sign criteria
  • Failure to escalate transport delays to senior staff
  • Lack of medically agreed timeframe for transfer
  • Incorrect information (osteomyelitis vs septic joint) passed between agencies

Coroner's recommendations

  1. Dr N. (also known as Robert Hakwa) be referred to AHPRA Medical Council of NSW for investigation of his clinical conduct
  2. Glen Innes District Hospital undertake audit process of appropriate nursing records including Standard Audit General Observation charts, fluid charts, recording of hourly rounding and recording of observations, at least twice yearly for two years
  3. Communications between transport agencies in relation to patient transfer should involve the treating doctor whenever possible, especially regarding potential changes to medically agreed timeframe
  4. Inter-hospital booking for specialist treatment cannot be made with Patient Transport Services unless medically agreed timeframe agreed between sending and receiving doctors and recorded in system
  5. Hunter New England Local Health District urgently address issues with pilot Medically Agreed Timeframe Project including solutions for obtaining MAT, force function implementation, enforcement mechanisms for updating MAT, clarification of escalation triggers, and removal of pre-generated time estimates
  6. Patient Flow Unit should record telephone calls to improve training and performance and assist with accurate audits of patient transfers within medically agreed timeframe
  7. NSW Ambulance consider undertaking audit of outcomes from overflow transfer requests including whether triaged through Virtual Clinical Coordination Centre, whether undertaken within 24 hours, and circumstances of transfers sent back to Patient Transport Services
Full text
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