Deceased
Kathleen Schleibs
Demographics
88y, female
Coroner
Coroner Audrey Jamieson
Date of death
2016-08-28
Finding date
2019-02-21
Cause of death
Sepsis complicated by multiple organ failure in a woman with comorbidities in the setting of recent shoulder surgery
AI-generated summary
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: inadequate assessment before discharge from acute care despite uncontrolled pain and ongoing opioid toxicity; discharge to a low-care facility unable to provide needed medical support; failure to perform C-reactive protein testing or urine culture after catheter removal despite signs of delirium; and delayed recognition/escalation of deterioration at the residential facility. The woman experienced uncontrolled postoperative pain requiring frequent breakthrough analgesia, was transported unaccompanied in a taxi while acutely confused, and deteriorated over hours before emergency services were called. Better pain assessment before discharge, consideration of higher-level care options, and systematic evaluation of delirium as a potential indicator of infection might have prevented this death.
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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