Demographics
64y, male
Coroner
Kirkegaard
Date of death
2016-05-24
Finding date
2018-08-20
Cause of death
Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia), with ischaemic heart disease as significant other condition
AI-generated summary
RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaemia, metabolic acidosis). The locum doctor and nurses failed to recognize sepsis or clinical deterioration. Critical errors included: misinterpreting elevated troponin as renal failure alone, not initiating antibiotics despite infection signs, not correcting hyperkalaemia, and transferring him by ambulance at 2-3 AM despite worsening hypotension (down to 84/42 mmHg by 3:40 AM) meeting MET criteria. He deteriorated severely en route, requiring ICU at another hospital where he died 48 hours after presentation. Earlier antibiotics, electrolyte correction, inotropes, and ICU review at the first hospital could have changed the outcome. Key lessons: recognize sepsis early despite diagnostic uncertainty, act on objective vital sign trends, escalate to senior staff when patients deteriorate, and avoid transfers of unstable patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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