Coroner's Finding: BROADWAY Rita Ann
Deceased
Rita Ann Broadway
Demographics
66y, female
Date of death
2015-01-02
Finding date
2017-11-15
Cause of death
urinary tract infection with contributing hypertensive heart disease, diabetes mellitus and bladder catheterisation
AI-generated summary
Rita Ann Broadway, 66, died from urinary tract infection on 2 January 2015, one day after presenting to Modbury Hospital Emergency Department with vaginal pain and signs of infection. She had a long-term indwelling catheter placed for urinary incontinence. The ED doctor did not recognize catheter-associated urinary tract infection (CAUTI) despite key clinical indicators: abnormally low temperature (35.5°C), acute pelvic pain, and urinalysis positive for leucocytes, nitrites, and protein. The SAAS paramedics' report documenting catheter 'flooding' was not integrated into clinical decision-making. The doctor declined her explicit request for catheter change. Expert evidence concluded that if the catheter had been changed and antibiotics given, her survival chances would have exceeded 80-90%. The following morning, RDNS declined her repeated request for catheter change, appearing not to recognize ongoing infection. The death was potentially preventable with appropriate recognition and management of CAUTI.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to recognise catheter-associated urinary tract infection despite clinical indicators
- abnormally low temperature (35.5°C) not recognised as sign of sepsis
- urinalysis findings (leucocytes, nitrites, protein) not integrated with clinical presentation
- SAAS patient report documenting catheter 'flooding' not reviewed by ED doctor
- patient's explicit request for catheter change refused
- no urine culture sent despite indwelling catheter and clinical presentation
- no blood investigations (FBC, CRP) performed despite diabetes and fever-like illness
- no antibiotics prescribed
- patient described as 'difficult historian' which may have biased assessment
- RDNS telephone assessment next morning not recognising ongoing signs of infection
- systemic failure to integrate available clinical information
Coroner's recommendations
- Minister for Health investigate development of a protocol for diagnostic criteria for catheter-associated urinary tract infection in adults within South Australian health system, using the document 'Diagnostic criteria for Catheter-Associated Urinary Tract Infection (CAUTI) in adults' as a starting point
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