Coroner's Finding: DAVIES Harold Leslie
Deceased
Harold Leslie Davies
Demographics
87y, male
Date of death
2005-07-18
Finding date
2009-06-26
Cause of death
multi organ failure due to septic shock complicating urinary tract infection and traumatic bladder catheterisation
AI-generated summary
An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful attempt by an RDNS nurse followed by a procedure by the patient's GP. Subsequently, massive haematuria developed. An ambulance was initially called but cancelled on the GP's instructions before being re-called; the delay may not have altered outcomes. Key issues included: the appropriateness of catheterisation in a nursing home setting given anticoagulation, the patient's preference for RDNS over his GP based on prior discomfort, uncertainty about which procedure caused the trauma, and failure to provide antibiotic prophylaxis despite chronic catheterisation and infection history. The case illustrates risks of performing invasive procedures in uncontrolled environments in vulnerable patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- traumatic bladder catheterisation
- warfarin anticoagulation
- chronic urinary tract bacterial colonisation
- difficult catheterisation history
- lack of antibiotic prophylaxis
- delay in ambulance transfer
- catheterisation performed in nursing home rather than hospital
- patient's unexpressed preferences regarding provider not communicated to GP
Coroner's recommendations
- Department of Health, Medical Board of South Australia and Nurses Board of South Australia to draw circumstances of the case to attention of medical and nursing professions
- Department of Health to review circumstances for appropriateness of catheterisation procedures in nursing homes and design protocols accordingly
- Department of Health and Nursing Board of South Australia to encourage nursing agencies to amend protocols and nursing alerts to include awareness of patient anticoagulation status
- Department of Health and Medical Board of South Australia to remind medical practitioners to consider desirability of antibiotic therapy and patient anticoagulation status when performing catheterisation procedures
- Department of Health, Medical Board of South Australia and Nursing Board of South Australia to remind constituents to consider transfer to hospital in difficult catheterisation cases, particularly where bleeding occurs
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