Finding into death of Graeme William Dimsey

Contributing factors

• Failure to perform joint aspiration despite clinical suspicion of prosthetic joint infection
• Reluctance to aspirate knee based on unreasonable fear of introducing infection
• Failure to identify alternative infection sources in timely manner
• Inadequate multidisciplinary team discussion and consultation
• Delayed diagnosis of right hip fracture following fall from bed
• Intellectual disability and delirium complicating clinical assessment and history-taking
• Incomplete examination following unwitnessed fall
• Misinterpretation of chest x-ray findings
• Failure to perform planned aspiration procedure

Coroner's recommendations

1. Grampians Health conduct a review of circumstances surrounding the death to produce guidelines for staff regarding assessment and management of patients with disability, cognitive impairment, mental health conditions, or other factors contributing to difficult, unreliable or inconsistent clinical assessment, particularly relating to patient history-taking and physical examination
2. Grampians Health conduct a review of scientific literature on risk of iatrogenic complications of diagnostic joint aspiration and produce evidence-based guidelines, developed at multidisciplinary consultant level, to balance risk of complication with risk of missing joint infection diagnosis in septic patients where joint infection may be implicated