Coronial
VIChospital

Finding into death of Ingeburg Hildegard Muller

Deceased

Ingeburg Hildegard Muller

Demographics

85y, female

Coroner

Coroner Audrey Jamieson

Date of death

2018-08-28

Finding date

2021-12-06

Cause of death

Staphylococcus bacteremia complicating multiple injuries sustained in a motor vehicle accident

AI-generated summary

An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and three surgical fixations. Initial recovery appeared successful, but she developed a wound infection post-discharge to rehabilitation. She was readmitted with deep wound infection, underwent washouts, and subsequently developed septic shock from Staphylococcus bacteremia secondary to acute kidney injury, dying on 28 August 2018. Clinical lessons include vigilance for post-operative wound complications especially after discharge, early recognition and aggressive management of surgical site infections, and coordination of care between hospital and rehabilitation settings. The collision itself involved a driver with significantly impaired vision (6/12 and counting fingers) who had never been reported to licensing authorities despite his medical conditions.

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

Specialties

emergency medicineintensive careorthopaedic surgerygeneral surgeryrehabilitation medicineinfectious diseases

Error types

system

Drugs involved

antibioticsbroad spectrum antibiotics

Clinical conditions

multiple bilateral rib fracturespelvic fracturesthoracic spine fracturepneumoniaurinary tract infectionsepsissurgical site infectionwound dehiscencestaphylococcus aureus bacteraemiaseptic shockacute kidney injury

Procedures

surgical fixation of fracturessurgical wound washoutvacuum-assisted closure dressing application

Contributing factors

  • Post-operative wound infection (pseudomonas) following surgical fixation
  • Multiple episodes of thoracic spine wound dehiscence during rehabilitation
  • Deep wound infection following readmission
  • Septic shock secondary to wound infection
  • Acute kidney injury (oliguric) secondary to sepsis
  • Patient refusal of dialysis

Coroner's recommendations

  1. Boroondara City Council continue review the design and layout of the three-way intersection of High Street and Marquis Street in light of the circumstances of this collision and consider improve the existing infrastructures
  2. Boroondara City Council replace the existing advisory speed limit sign of 40 kilometres per hour between the hours of 7.00am to 7.00pm along the northbound lane of Marquis Street to a warning sign of 'Raised Intersection' with advisory speed limit of 40 kilometres per hour
  3. Boroondara City Council introduce a more contrasting grey coloured pavement marking on the raised safety platform
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