Inquest into the Death of Ford, Valma May Ruth

Contributing factors

• Unrecognized or inadequately managed perioperative urinary tract infection (E. coli)
• Acute sepsis secondary to UTI and possible chest infection
• Acute on chronic heart failure and cardiovascular decompensation
• Suboptimal INR reversal prior to surgery due to atypical Warfarin response and missed overnight Vitamin K dose
• Inadequate night medical cover resulting in delayed treatment decisions
• Single-dose perioperative antibiotic prophylaxis without continuation despite risk factors
• Fluid overload secondary to aggressive fluid resuscitation for persistent hypotension
• Pressure sores with associated compromised skin barrier
• Chronic renal impairment with borderline function unable to tolerate additional physiological stress
• Pre-existing coronary artery disease and atherosclerotic burden

Coroner's recommendations

1. WACHS consider increasing the education of staff and reinforcing the need for and requirements of documentation, including timing entries, documenting family concerns, and communications between doctors and nurses.
2. WACHS to consider increasing education of staff and reinforcing the need for staff to communicate with patients and their families in relation to the patient's treatment and plan for care.
3. The pathology request forms in use have a clear field for the urgency of results, and there be a protocol as to when and how results are delivered, and to whom.
4. WACHS continue with the audits already in place to ensure real time appropriate adherence to policies procedures, documentation and the relevant completion of all forms requiring action.