Finding into death of HJW
Deceased
HJW
Demographics
69y, female
Date of death
2024-06-26
Finding date
2026-07-01
Cause of death
Urosepsis secondary to anuric acute renal failure and corona radiata infarct; contributing factors emphysematous pyelitis and candidaemia
AI-generated summary
A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming kidney infection). Despite clear warning signs of developing sepsis over 19 hours—including progressive falls in diastolic blood pressure, widening pulse pressure, tachycardia, and family concerns—no escalation to medical review occurred until a MET call at 7:47pm when blood pressure fell to 86/54. Critically, IV fluids were not initiated until the MET call, despite her being a vomiting diabetic with serious infection. She deteriorated into septic shock, required ICU admission, and died on 26 June 2024 from urosepsis with multi-organ failure. The coroner identified multiple missed opportunities for earlier recognition and intervention. Eastern Health accepted the finding as a Sentinel Event and implemented system improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Emphysematous pyelitis
- Failure to recognize early sepsis
- Lack of IV fluid resuscitation for 19 hours despite vomiting and significant infection
- Delayed escalation despite abnormal observations (falling diastolic BP, widened pulse pressure, tachycardia)
- No medical review at times of abnormal observations
- Type 2 diabetes mellitus
- Candidaemia
- Family concerns not adequately escalated
Coroner's recommendations
- Improve Emergency Department and General Medicine clinician awareness of occult serious infections and atypical presentations of sepsis
- Present case at Mortality and Morbidity meetings focusing on diagnostic and management delays
- Strengthen system processes to ensure timely IV fluid resuscitation for infected patients with inadequate oral intake
- Strengthen clinical practice, communication, and escalation processes including improved recognition of family concerns
- Review definition of 'expected death' to include care provided in emergency department prior to MET call (completed)
- Classify death as Sentinel Event Category 11, Subcategory 3 (prolonged delay in recognizing and responding to deterioration) (completed)
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