Coroner's Finding: Handasyde, Robert Neil
Deceased
Robert Neil Handasyde
Demographics
86y, male
Date of death
2015-06-27
Finding date
2017-05-08
Cause of death
Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney infection) and focal areas of infection in the prostate gland
AI-generated summary
An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and nocturia, suggesting bladder neck obstruction. This diagnosis was missed by the GP and subsequently by hospital staff during an April admission for rectal bleeding. The obstruction led to urinary retention, infection of retained urine, and fatal sepsis. Timely urological assessment and catheterisation or surgery would likely have prevented death. Critical failures included: incomplete history-taking, failure to diagnose bladder obstruction despite clear clinical indicators, inappropriate oral antibiotic monotherapy for septic shock (requiring IV antibiotics and hospital admission), and excessive opioid dosing causing toxicity in a patient with renal impairment. The nursing home should have escalated to hospital when the GP failed to attend on 19 June despite signs of septic shock.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
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
- Improved clinical assessment and history-taking to identify bladder obstruction presenting with incontinence and nocturia
- Timely urological referral for patients with evidence of bladder neck obstruction
- Recognition that septic shock requires emergency hospital admission and IV antibiotic therapy, not oral antibiotics alone
- Appropriate opioid dosing with adjustment for renal impairment
- 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
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