An 87-year-old woman with dementia, heart failure, and cerebrovascular disease died of sepsis on an aged psychiatry unit. She was admitted under mental health legislation following behavioural deterioration. On 11 March, she was diagnosed with urinary tract infection and probable chest infection and commenced on antibiotics. Her condition did not improve, and she was found unresponsive the following morning. The coroner found sepsis as the cause of death with contributing factors being her comorbidities. The finding does not identify specific clinical errors or preventable factors. Key lessons include the need for careful assessment of infection in elderly patients with dementia and multiple comorbidities, timely escalation of care when antibiotics fail, and consideration of the complexity of managing acute illness in psychiatry units.
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