Coroner's Finding: Powell, Arthur John
Deceased
Arthur John Powell
Demographics
90y, male
Date of death
2015-10-06
Finding date
2016-10-31
Cause of death
Sepsis secondary to wound infection/dehiscence and bilateral parotid gland infection following surgical repair of perforated diverticulum
AI-generated summary
Arthur John Powell, a 90-year-old with ischaemic heart disease, chronic lung disease, and diabetes, underwent emergency surgical repair of a perforated diverticulum on 1 September 2015. Post-operative recovery was initially good. However, his surgical wound deteriorated from wet (19 September) to 'terrible' (23 September) but was never reviewed by the surgeon and was not treated with antibiotics despite clear infection signs. Mr Powell developed bilateral parotid gland infection and was discharged on 25 September while still infected. He deteriorated at the nursing home and was re-admitted with septic shock, acute kidney injury, and Staphylococcus aureus bacteremia, dying 6 days later. The coroner found the wound management 'ineffective', failure to review the wound 'a poor decision', failure to recognize and treat infection 'regrettable', and discharge while infected 'a poor decision'. Treatment fell short of expected standard. Critical lessons: regular post-operative wound assessment, prompt recognition and treatment of surgical site infections, and appropriate discharge decisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Surgical wound not reviewed by surgeon post-operatively
- Failure to recognize surgical wound infection despite visible signs of deterioration
- Failure to treat surgical wound infection with antibiotics
- Inappropriate discharge from hospital while patient had active suppurative parotitis
- Patient's intermittent refusal of treatment and food
- Depression during hospitalization
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