Deceased
Justin DOBSON
Demographics
46y, male
Coroner
Deputy State Coroner Linton
Date of death
2019-07-19
Finding date
August 2023
Cause of death
sepsis following haemorrhoidectomy
AI-generated summary
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension, tachycardia, and urinary retention. Clinical and laboratory clues of early sepsis—raised creatinine and urea, elevated heart rate and low blood pressure in a post-operative patient—were present by 1:35 pm. By 3:00 pm, when he met MET call criteria, appropriate escalation to the operating surgeon and transfer to a tertiary hospital should have occurred. Instead, the clinical deterioration was attributed to pain, anxiety, and medication effects. A MET call was not made until 9:30 pm when Mr Dobson was in profound septic shock. Antibiotics were not commenced until 11:25 pm. Critical missed opportunities were: failure to escalate to the operating surgeon (Mr Filgate) when Mr Dobson was not discharged as expected; failure to make a MET call at 3:00 pm when observations met criteria; and failure to provide a handover to the after-hours doctor. Earlier recognition and transfer would likely have substantially improved survival chances from >90% at 3:00 pm to <10% by the time antibiotics were finally given.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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