Finding into death of Christopher Gerard McIntosh
Deceased
Christopher Gerard McIntosh
Demographics
54y, male
Date of death
2022-05-10
Finding date
2025-10-28
Cause of death
Respiratory failure secondary to prolonged ventilation for management of sepsis due to infected foot ulcer requiring above-knee amputation in a man with diabetes mellitus
AI-generated summary
Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarcerated at Hopkins Correctional Centre when his condition deteriorated. Critical clinical lessons include: (1) patients with chronic diabetic ulcers refusing treatment require enhanced vigilance and structured monitoring; (2) wound care management must include documented patient education even when patients insist on self-care; (3) absence of documented follow-up on specialist referrals (podiatrist, high-risk foot team) represents a significant care gap; (4) poor record-keeping and lack of formalized wound assessment tools compromised care continuity. While McIntosh declined hospitalization for personal reasons (NDIS funding, prison transfer concerns), the coroner found no evidence that earlier transfer would have changed outcome, though specialist opinion noted the infection was substantially more severe by admission. Key preventive measures: implement structured wound management pathways, ensure documented patient education, maintain rigorous follow-up on specialist recommendations, and improve record-keeping systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- chronic diabetic foot ulcers with poor compliance with treatment
- patient refusal of hospitalization and intravenous antibiotics
- lack of documented wound care education and training
- absence of documented follow-up on specialist (podiatrist, high-risk foot team) referrals
- poor record-keeping and lack of structured wound assessment tools
- gap of two weeks without documented wound assessment between 19 March and 4 April 2022
- delay in hospital transfer from 5 to 7 April 2022 (though severity suggests this may not have altered outcome)
- apparent absence of formalized intervention plan for wound management
Coroner's recommendations
- Health service providers develop health pathways to guide clinicians in assessment, treatment, and management of patients, including information on referral pathways for relevant services and specialists
- All health service providers review and update current wound management policies to include wound care management assessment tools and patient information sheets
- Justice Health update their system to include wound management assessment tools and patient information sheet templates to be completed by staff
- Hopkins Correctional Centre undertake an audit of compliance with Local Plan discussion requirements outlined in relevant policy, including review of frequency and documentation of case manager meetings
- Hopkins Correctional Centre address any barriers and rectify gaps identified by the audit
Full text
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