Deceased
Glenn Howard Raphael
Demographics
74y, male
Date of death
2001-06-21
Finding date
2006-01-25
Cause of death
cardiac and renal failure complicating treatment of infected ischaemic toes resulting from diabetes mellitus
AI-generated summary
Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failures included: failure to monitor creatinine and gentamicin levels between 9-18 June despite prescribing three nephrotoxic drugs (gentamicin, celecoxib, ramipril). A vascular registrar prescribed gentamicin; a consultant physician subsequently added ramipril on 13 June for cardiac optimisation—laudable long-term thinking but unnecessary given the acute presentation. Creatinine rose dramatically from 0.100 to 0.319 mmol/L undetected over 6 days. Although monitoring failure is clear, whether earlier detection would have prevented death remains uncertain. Key lesson: in acutely unwell patients already on nephrotoxic antibiotics, adding further nephrotoxic agents requires robust concurrent monitoring supervision. Registrars bear primary responsibility for overseeing junior doctor-ordered tests.
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
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