Coronial
VICaged care

Finding into death of Ellen Plymin

Deceased

Ellen Plymin

Demographics

85y, female

Date of death

2007-06-27

Cause of death

Sepsis relating to an infected right shoulder wound (including MRSA)

AI-generated summary

Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound swabs revealed MRSA infection. Her GP, Dr M., consulted a microbiologist and arranged topical betadine dressings, believing the infection was superficial. The family requested hospital admission on 1 June, but Dr M. refused. By 4 June, the wound deteriorated with brown ooze and offensive odour; Dr M. interpreted this as beneficial drainage. She was finally readmitted 6 June, when deep joint infection was discovered. Multiple surgical interventions followed. She died 27 June from sepsis with cardiac and respiratory complications. The coroner identified a diagnostic error in misinterpreting a deep joint infection as superficial, but found the decision to manage at aged care was 'not necessarily unreasonable' given specialist consultation and her complex medical history.

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

Contributing factors

  • Post-operative wound infection with methicillin-resistant Staphylococcus aureus (MRSA)
  • Misdiagnosis of deep joint infection as superficial wound infection
  • Delayed recognition and escalation of wound deterioration
  • Initial management with topical betadine rather than hospital admission with intravenous antibiotics
  • Antibiotic allergies limiting treatment options
  • Failure to escalate family's request for hospital admission
  • Reliance on clinical appearance stability despite worsening wound characteristics
  • Limited oversight of wound deterioration between 1 and 4 June 2007
  • Complex medical history with significant cardiac comorbidities
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