Inquest into the death of Joanne Craig
Deceased
Joanne Craig
Demographics
57y, female
Date of death
2018-01-24
Finding date
2019-09-20
Cause of death
multi-organ failure due to sepsis caused by streptococcus pneumoniae infection
AI-generated summary
Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 11:41am onwards, indicating bacterial infection. Despite fulfilling sepsis criteria and showing haemodynamic deterioration from 3:30pm with hypotension (86/54) consistent with septic shock, antibiotics were not commenced until 7:20pm. She died at 9:25pm. Multiple failures occurred: her GPs did not administer recommended Pneumovax23 vaccination (she was Aboriginal, age 57); the ED failed to recognise sepsis despite clear indicators; and critical handover between ED and ward at 3:30pm lacked specificity, resulting in failure to escalate or initiate antibiotics until cardiac arrest was imminent. Earlier antibiotic therapy (by midday-3:30pm) would likely have saved her life.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- failure to recognise sepsis in emergency department despite elevated inflammatory markers (WCC 18.7, neutrophils 14.2, CRP 26)
- failure to recognise septic shock when blood pressure dropped to 86/54 mmHg at 3:30pm
- delayed antibiotic administration until 7:20pm (10 hours after presentation)
- poor clinical handover between ED and ward at 3:30pm without documentation of findings
- failure to escalate to senior staff despite abnormal observations after transfer to ward
- absence of fluid balance chart limiting clinical assessment
- failure of general practitioners to offer Pneumovax23 vaccination despite Aboriginal status and age
- inadequate sepsis recognition pathway at the time of presentation
Coroner's recommendations
- General Practitioners should have a schedule for and make every effort to provide Pneumovax23 (23vPPV) vaccination to Aboriginal and Torres Strait Islander people in accordance with the Australian Immunisation Handbook
- Top End Health Service should do all things necessary to ensure its staff are competent in the recognition of sepsis and escalation of treatment, with ongoing efforts
- Top End Health Service should do all things necessary to ensure that the documentation utilised when treating patients is appropriate and appropriately utilised
- Documentation utilised should be audited on a regular basis
Full text
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