TAShospital

Coroner's Finding: Tetley, Barry Lindsay

Deceased

Barry Lindsay Tetley

Demographics

72y, male

Date of death

2013-04-01

Finding date

2014-09-19

Cause of death

sepsis of undetermined source (pneumonia or spinal epidural abscess)

AI-generated summary

A 72-year-old man presented to ED with back pain, fever, elevated inflammatory markers (CRP 77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these findings, he was discharged without vital signs being rechecked or documented, without examination by the discharging doctor, and without septic workup or imaging. Hours later he collapsed with septic shock and died despite ICU admission. The coroner found sepsis (likely from pneumonia or spinal epidural abscess) was the cause. Clinical lessons: sepsis presents atypically (back pain can be a presenting symptom); vital sign fluctuations must be monitored closely; abnormal labs (fever, elevated CRP, low albumin, low sodium, elevated ALP) in context of focal pain warrant septic screen and blood cultures; discharge requires documented clinical review with vital signs and case summary; 95% survival was possible with appropriate treatment.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineintensive caremicrobiologyinfectious diseases

Error types

diagnosticcommunicationsystem

Clinical conditions

sepsiscommunity-acquired pneumoniaspinal epidural abscessaspiration pneumoniahyponatraemiahypoalbuminaemiasystemic inflammatory responsestreptococcus agalactiae infection

Procedures

intubationmechanical ventilationcardiopulmonary resuscitation

Contributing factors

failure to recognise sepsis on clinical presentation
failure to act on abnormal vital signs (hypotension 98/59)
failure to act on abnormal laboratory results (elevated CRP, elevated WBC with neutrophilia, low sodium, low albumin, elevated alkaline phosphatase)
failure to perform clinical examination prior to discharge
failure to take vital signs prior to discharge
failure to order septic screen or blood cultures
failure to order chest X-ray or spinal imaging
failure to initiate empiric antibiotic therapy
inadequate documentation of clinical review
missed atypical presentation of pneumonia (back pain as presenting symptom)
aspiration pneumonia superimposed perimortem

Coroner's recommendations

Remind the medical fraternity that sepsis is a life-threatening condition often difficult to diagnose due to multiple presentations and fluctuating signs, requiring close vigilance of vital signs
Hospitals should not discharge patients without first undertaking a review of their medical status including taking and recording vital signs
Discharge review should include re-examination of observation charts, blood results, radiology examinations, and a brief case summary entered into the medical record
Medical practitioners must be alert to multiple presentations of sepsis, including atypical presentations such as back pain as a presenting symptom of community-acquired pneumonia

Full text

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