Coronial
QLDhospital

A Patient - Non-inquest findings

Demographics

66y, male

Coroner

Lock

Date of death

2013-06-02

Finding date

2014-09-03

Cause of death

legionella pneumophila pneumonia

AI-generated summary

A 66-year-old man with multiple myeloma undergoing chemotherapy died from legionella pneumonia acquired from the Wesley Hospital water system. He was immunocompromised due to chemotherapy and corticosteroids, making him particularly vulnerable to atypical infections. The legionella organism (serotype 1) was identified in his urine on 27 May 2013, appropriate antibiotics were promptly prescribed, but his condition deteriorated due to concurrent cytomegalovirus co-infection and acute pulmonary oedema. The coroner found no concerns with clinical care delivery; all diagnosis and intervention was timely with appropriate specialist consultation. Key system failures included delayed notification of the positive legionella test by the pathology laboratory (due to laboratory information system deficiencies) and failure to connect a previous 2011 legionella death to the hospital water infrastructure. The case highlights the importance of robust water quality management in hospitals to protect immunocompromised patients and timely notification of notifiable conditions.

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

Specialties

infectious diseasesoncologycardiologyintensive carepalliative carepathologypublic health

Error types

systemcommunicationdelay

Drugs involved

chemotherapycorticosteroidsantibiotics

Clinical conditions

legionella pneumoniamultiple myelomaimmunocompromised stateischaemic heart diseasecytomegalovirus co-infectionpleural effusionacute pulmonary oedemaamyloidosis

Procedures

pleural effusion drainagepleural drain insertionintensive care unit admissionrespiratory assistance

Contributing factors

  • immunocompromised state due to chemotherapy and corticosteroids for multiple myeloma
  • exposure to legionella from hospital water system
  • cytomegalovirus co-infection
  • acute pulmonary oedema
  • legionella proliferation in warm water systems
  • delayed notification of positive legionella test by pathology laboratory
  • failure to connect previous 2011 legionella death to hospital water infrastructure

Coroner's recommendations

  1. Public and private hospitals and residential aged care facilities develop water quality risk management plans, which include periodic testing of their water supplies
  2. In the medium term, legislation be strengthened relating to the design, commissioning, installation, operation and maintenance of cooling water systems and water delivery systems in hospitals and residential aged care facilities
  3. A memorandum of understanding be developed by relevant regulatory agencies to clearly articulate the roles of each agency and coordination arrangements with respect to legionella risks in hospitals and residential aged care facilities
  4. National collaboration be sought with regard to strengthening and finalising Australian standards and guidelines for the operation and maintenance of drinking water systems
  5. Accreditation processes for hospitals and residential aged care facilities should be reviewed to determine if aspects relating to the physical environment should be strengthened
  6. An immediate upgrade of the Notifiable Conditions System be progressed
  7. A review of information for the community be undertaken to increase awareness of legionella risks and how to minimise them
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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