Coroner's Finding: Handasyde, Robert Neil

Contributing factors

• Failure to diagnose bladder neck obstruction on 26 March 2015 despite clear clinical presentation
• Incomplete history-taking and failure to obtain full clinical picture
• Missed opportunity for urological referral in March 2015
• Failure to diagnose bladder obstruction during April 2015 hospital admission despite urinary retention and 700ml bladder scan findings
• Inappropriate treatment of presumed septic shock with oral antibiotic monotherapy instead of IV antibiotics and hospital admission on 19 June
• Excessive opioid dosing (20mg endone in 48 hours) without adjustment for renal impairment, causing toxicity
• Failure of nursing home to escalate to hospital on 19 June when GP did not attend and patient showed signs of septic shock
• Infection of retained urine leading to pyelonephritis and septicaemia

Coroner's recommendations

1. Improved clinical assessment and history-taking to identify bladder obstruction presenting with incontinence and nocturia
2. Timely urological referral for patients with evidence of bladder neck obstruction
3. Recognition that septic shock requires emergency hospital admission and IV antibiotic therapy, not oral antibiotics alone
4. Appropriate opioid dosing with adjustment for renal impairment
5. Nursing homes should escalate to hospital on their own initiative when signs of septic shock are present and the expected GP review does not occur