Deceased
Charles Thomas Wilson
Demographics
85y, male
Date of death
2022-12-10
Finding date
2026-04-23
Cause of death
Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left shoulder on a background of congestive cardiac failure
AI-generated summary
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate medical care, a critical medication error occurred when Mr Wilson was transferred to Port Augusta Prison: newly prescribed cardiovascular medications (bisoprolol and digoxin) were not documented on his medication chart, and he did not receive them. The Queen Elizabeth Hospital discharge summary identified this medication error as the 'trigger' for his decompensated heart failure requiring ICU admission. Although the error was significant and required emergency retrieval and intensive care, the coroner found it did not cause or significantly contribute to his ultimate death. The case highlights the importance of medication reconciliation during prisoner transfers between facilities, particularly for complex cardiac 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
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
79y · Male·myocardial infarction
Brian Davies, 79, died of myocardial infarction while under an Inpatient Treatment Order for Alzheimer's dementia at Noarlunga Hospital. He presented with cognitive decline following his partner's death and developed agi…
79y · Female·multi-organ failure as a result of ischaemic and valvular heart disease with uri…
Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 …
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