Coronial
VIChospital

Finding into death of John Manias

Deceased

JOHN MANIAS

Demographics

63y, male

Coroner

Coroner Peter White

Date of death

2008-03-11

Finding date

2015-04-29

Cause of death

Multisystem organ failure, pneumonitis and sepsis; complications arising from a fall resulting in multiple rib fractures

AI-generated summary

A 63-year-old man died on 11 March 2008 from multisystem organ failure, sepsis and pneumonitis following a fall. He was admitted to Dandenong Hospital with rib fractures and pelvic injuries. Clinical deterioration occurred over several days. Critical blood tests showing elevated creatinine (229 mmol/L) and CRP (401.3) were taken on 8 March 2008 but not reviewed until 10 March, when a MET call was made. He was transferred to ICU with septic shock secondary to staphylococcus aureus pneumonia. The infection likely originated from an IV line noted to be inflamed on 4 March and redened/swollen on 9 March, without further investigation. The coroner found that earlier review of the 8 March blood tests would likely have led to earlier diagnosis, investigations and treatment, with a favourable outcome. Key lessons: systems must ensure critical laboratory results are promptly accessed and acted upon; IV sites require regular monitoring and escalation when signs of infection appear; family concerns should be actively evaluated.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

trauma surgeryorthopaedic surgeryintensive careemergency medicinepathology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

ceftriaxoneazithromycin

Clinical conditions

septic shockstaphylococcus aureus infectionpneumoniapneumonitisacute renal failuremultiple rib fracturespelvis fracturemultisystem organ failureIV site infection

Procedures

intravenous line insertion

Contributing factors

  • Blood test results taken on 8 March 2008 not reviewed until 10 March 2008
  • Elevated creatinine and CRP levels not identified and acted upon in timely manner
  • IV line site showing signs of infection (redness, swelling) noted on 4 March and 9 March but not investigated
  • No formal critical results notification protocol for creatinine and CRP in place at time
  • Staphylococcus aureus infection likely originating from IV line not recognised until ICU admission

Coroner's recommendations

  1. Critical biochemistry results including creatinine and CRP levels should be added to the list of results requiring phone notification to ordering doctors when at critical levels
  2. IV sites should be regularly monitored for signs of infection and investigation undertaken when redness or swelling is identified
  3. Blood test results must be accessed and reviewed promptly by ordering clinicians
  4. Improved communication with families regarding patient condition and concerns
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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