Coroner's Finding: Davis, Graeme Charles
Deceased
Graeme Charles Davis
Demographics
56y, male
Date of death
2018-01-27
Finding date
2021-04-12
Cause of death
sepsis
AI-generated summary
A 56-year-old man died from sepsis following elective bladder cancer surgery. Post-operative infection developed with clear clinical signs: elevated CRP (205-284 mg/L), positive bacterial cultures (Staphylococcus aureus, Klebsiella pneumoniae), fever, wound drainage, and systemic symptoms from 16 January onwards. Despite obvious infection markers from 20 January, antibiotics were not commenced until 25 January—five days later and too late. The surgical team attributed the wound appearance to non-infectious causes and failed to recognise sepsis severity. Antibiotic administration was also delayed once prescribed. The coroner found this death entirely avoidable, caused by failure to diagnose infection, failure to initiate timely antibiotics despite clear laboratory evidence, and subsequent delays in administration. Early recognition of sepsis signs and prompt antibiotic therapy would likely have prevented death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to diagnose sepsis despite clear clinical and laboratory evidence
- failure to initiate antibiotics despite elevated CRP (205-284 mg/L) and positive blood cultures
- delay in antibiotic administration once prescribed
- failure to recognise severity of infection in post-operative patient
- misinterpretation of clinical findings as non-infectious
- inadequate response to laboratory markers of bacterial infection
- fluid collection in pelvis not appropriately managed
- failure to escalate care to ICU despite positive blood culture and sepsis
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