Coronial
QLDhospital

RD - Non-inquest findings

Demographics

64y, male

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.

Specialties

emergency medicineintensive careparamedicinegeriatric medicine

Error types

diagnosticmedicationcommunicationsystemdelay

Drugs involved

intravenous normal salineapple juicepiperacillin/tazobactamadrenalineinsulin/dextrose infusionsodium bicarbonatetriple intravenous antibiotics

Clinical conditions

sepsisurosepsisseptic shockacute kidney injuryhyperkalaemiametabolic acidosishypotensionmyocardial ischaemiaatrial fibrillationmulti-organ failureurinary tract infectiontype 2 diabetes mellituschronic obstructive pulmonary diseaseischaemic heart diseasehypothermia

Procedures

intravenous cannulationindwelling urinary catheterizationintubationarterial line insertioncentral line insertionelectrocardiogramchest X-rayCT imagingdialysis

Contributing factors

  • Failure to recognize sepsis despite clinical presentation
  • Misinterpretation of elevated troponin as secondary to renal failure only
  • Failure to initiate antibiotics despite suspected infection and urinary tract findings
  • Inadequate management of hyperkalaemia
  • Failure to correct metabolic acidosis
  • Inadequate management of hypotension
  • Inappropriate focus on getting patient out of ED rather than reassessing stability
  • Transfer of haemodynamically unstable patient by ambulance
  • Incomplete handover to paramedics
  • Misattribution of confusion to dementia rather than acute illness
  • Failure to escalate to Intensivist On-Call
  • Lack of critical thinking regarding diagnosis
  • Busy ED with limited senior support
  • First night shift for locum doctor

Coroner's recommendations

  1. Develop and implement a cognitive assessment tool for the emergency department
  2. Work with local residential aged care facilities to develop a handover form and process for resident referrals to hospital
  3. Implement the Queensland Sepsis Pathway
  4. Deliver education to develop critical reasoning and critical thinking skills
  5. Targeted education for locum medical officers regarding the causes and management of hypotension
  6. Introduce the Rural & Remote Emergency Queensland Adult Deterioration and Detection System chart
  7. Education for emergency department staff about criteria for referral to Intensivist On-Call
  8. Review and circulate clinical escalation processes to emergency department staff
  9. Review clinical handover processes (from residential aged care facilities to hospital; from paramedics for admissions; to After Hours Manager)
  10. Ongoing education, audit and feedback to staff on clinical documentation standards
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