Deceased
David Reginald Crisfield
Demographics
43y, male
Coroner
Coroner Audrey Jamieson
Date of death
2007-11-07
Finding date
2012-02-06
Cause of death
Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pneumoniae pneumonia
AI-generated summary
David Crisfield, a 43-year-old immunosuppressed patient with COPD on Crohn's disease therapy, died from streptococcus pneumoniae septic shock. He presented to a rural hospital ED on 6 November 2007 with respiratory compromise and low oxygen saturation (83%). Dr Y. assessed him from across the room without examination, dismissing him as Category 5, influenced by the patient's smoking and drinking history rather than objective clinical assessment. The patient was discharged and seen next morning at a clinic, where Dr G. appropriately diagnosed probable pneumonia and attempted hospital admission. Given no local bed availability and patient reluctance, Dr G. permitted him home with antibiotics and clear return precautions. The patient deteriorated rapidly, was transferred to the tertiary hospital, and died within hours. A significant clinical opportunity was lost when Dr Y. failed to examine the patient and declined admission despite clear signs of serious respiratory infection. An expert opinion suggested that even two hours earlier antibiotic administration would likely not have changed the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
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