Inquest into the Death of Garry Small
Deceased
Garry Small
Demographics
71y, male
Date of death
2020-08-26
Finding date
2025-05-28
Cause of death
Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation therapy
AI-generated summary
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxone ordered but not charted at 1:00pm, flucloxacillin not given until 6:04pm, and ampicillin withheld due to ED unavailability. Management deviated from the Sepsis Pathway with inadequate repeat observations and lactate monitoring. He developed delirium (multifactorial: sepsis, medications including oxycodone 10mg and diazepam, frailty) and fell unwitnessed on day 2, sustaining a subdural haematoma requiring surgery. Although care was suboptimal, the coroner found the fall's cause multifactorial and could not conclude that timely antibiotics would have prevented it or materially altered the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Delayed antibiotic administration
- Non-compliance with Sepsis Pathway
- Delirium secondary to sepsis and medications
- Inadequate falls prevention measures
- Inappropriate medication prescribing (oxycodone 10mg, diazepam)
- Unavailability of ampicillin in ED
- Multifactorial fall risk including frailty, sepsis-induced delirium, orthostatic hypotension
- Insulin-dependent type 2 diabetes mellitus
- Hypertension
- Ischaemic heart disease
- Osteomyelitis with proteus mirabilis bacteraemia
Coroner's recommendations
- Integration of the Sepsis Pathway into the electronic medical record (eMR) to ensure consistent availability and use despite transition to new eMR systems
- Implementation of automated alerts within eMR systems for elevated lactate levels and Red Zone sepsis criteria to reduce reliance on manual escalation
- Continued training and education for junior and senior medical staff regarding Sepsis Pathway recognition and management
- Clarification of processes for sourcing alternative antibiotics when routine antibiotics are unavailable in ED (e.g., switch from ampicillin to amoxicillin)
- Review of medication stock levels and availability processes, particularly for antibiotics critical to sepsis management
- Enhanced falls prevention protocols for patients with delirium, including assessment of feasibility for 1:1 nursing or dedicated nursing cohorts
- Review of medication prescribing practices in delirious patients, with particular attention to avoidance of opioids and benzodiazepines that worsen delirium
- Clarification of documentation requirements for medication indications, particularly for opioids and sedatives
Full text
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