Inquest into the death of Joanne Craig

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

1. 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
2. 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
3. Top End Health Service should do all things necessary to ensure that the documentation utilised when treating patients is appropriate and appropriately utilised
4. Documentation utilised should be audited on a regular basis