Coroner's Finding: Henriksen, Wendy Margaret
Deceased
Wendy Margaret Henriksen
Demographics
72y, female
Date of death
2014-07-10
Finding date
2016-07-18
Cause of death
probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma
AI-generated summary
A 72-year-old woman died of sepsis complicating chemotherapy for non-Hodgkin's lymphoma. She presented to ED with severe abdominal pain, elevated lactate (6.1 mmol/L), and signs of shock. The surgical team failed to recognize evolving septic shock and did not escalate to ICU until 7:10pm, when her condition had critically deteriorated. By 1:00pm, vital signs clearly indicated septic shock (hypotensive, tachycardic, hypoxic), requiring immediate ICU admission. The oncology team was not consulted until 2:00pm despite critical illness and diagnostic uncertainty. Although a diagnostic laparotomy was appropriately not pursued given recent chemotherapy, the failure to transfer to ICU for maximal supportive care in early afternoon represented suboptimal care that reduced survival prospects, though death may not have been entirely preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to recognize evolving septic shock
- delayed escalation to ICU
- late consultation with oncology team
- immunosuppression from recent chemotherapy
- inability to identify definitive source of sepsis
- delay in transfer to ICU from 1:00pm until 7:10pm
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