Finding into death of Robert Charles Avery
Deceased
Robert Charles Avery
Demographics
86y, male
Date of death
2010-07-20
Finding date
2015-07-01
Cause of death
Septic shock secondary to urosepsis
AI-generated summary
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparation, and insulin adjustment. Despite overnight clinical deterioration (low blood pressure, rectal bleeding, poor oral intake), he was discharged on day 2. An emergency physician reviewed him post-midnight, ordered blood tests for morning, but did not directly communicate findings to the treating surgeon. The surgeon did not review the physician's notes or the ordered blood tests before discharge. Avery was readmitted next day with sepsis from a resistant urinary tract infection and died of septic shock. Key failures included: failure to review progress notes and blood test results before discharge, inadequate fluid balance documentation, poor communication between physicians, and failure to alert the treating doctor to abnormal pathology results. Early recognition of sepsis and appropriate fluid management might have altered the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadequate fluid balance documentation
- Failure to review progress notes made by emergency physician
- Failure to review ordered blood test results before discharge
- Failure to directly communicate between treating physicians
- Failure to alert treating doctor to abnormal pathology results (elevated CRP and neutrophilia)
- Poor oral intake post-procedure not adequately managed
- Urinary retention post-catheterisation discharged without trial of voiding
- Rectal bleeding not fully investigated
- Inadequate examination and documentation by treating surgeon
- Multiple comorbidities in elderly patient
Coroner's recommendations
- Hospital administrations must be vigilant in ensuring appropriate standards of medical record keeping are maintained
- Implementation of online pathology reporting systems that allow remote access to diagnostic results, display trends, enable flagging of abnormal results, and allow urgent actioning of results
- Ward staff competency assessments regarding IV cannulation protocols and care of patients with colostomy
- Bowel preparation policy review to include management of patients with stoma receiving bowel preparation
- Staff reiteration regarding importance of fluid balance documentation
- Reinforcement of discharge communication protocols to ensure patients and carers are advised to contact hospital or return to ED if complications arise post-discharge
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