Deceased
Colin Stanley Francis NICHOLSON
Demographics
69y, male
Coroner
Deputy State Coroner Linton
Date of death
2021-11-18
Finding date
2025-04-17
Cause of death
septic shock with multi-organ failure in a man with neutropenic sepsis on a background of recent acute myeloid leukaemia diagnosis
AI-generated summary
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refer blood films to haematology despite protocol requirements on 22 September and 5 October 2021, delaying AML diagnosis. When urgent referral was eventually made on 4 November 2021, it became lost in a CRS system backlog during COVID-19 delays. On 15 November 2021, Colin presented to Collie Hospital ED with fever, rigors, and critical neutropenia, but Dr V. failed to recognise neutropenic sepsis, did not initiate antibiotics, and discharged him inappropriately. Early recognition of febrile neutropenia and treatment on 15 November would likely have been salvageable; by 16 November when sepsis was finally diagnosed, it was too late. Key lessons: strict adherence to laboratory protocols, effective urgent referral pathways, and recognition that fever plus neutropenia requires immediate broad-spectrum antibiotics regardless of presumed viral versus bacterial infection.
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
1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.