Inquest into the Death of Colin Stanley Francis NICHOLSON
Deceased
Colin Stanley Francis NICHOLSON
Demographics
69y, male
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.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure of laboratory scientist to follow PathWest protocol HM026 requiring haematology referral for neutrophil count <1.0 x 10^9/L on 22 September 2021 and 5 October 2021
- Failure to identify or report abnormal cells (blasts) in blood films
- Delay in AML diagnosis from 22 September to 3 November 2021
- Urgent haematology referral sent 4 November 2021 became lost in CRS system backlog
- CRS processing delays of 7-8 business days in November 2021 due to COVID-19 pandemic backlog
- Failure of Dr V. to recognise febrile neutropenia on 15 November 2021 afternoon presentation
- Misinterpretation of blood results as viral infection rather than considering bacterial sepsis
- Failure to initiate antibiotics on 15 November 2021 despite fever, rigors, raised CRP, and severe neutropenia
- Inappropriate discharge from Collie Hospital ED on 15 November 2021 without antibiotics
- Lack of documentation regarding discharge planning
- 16-hour delay in antibiotic initiation between 15 and 16 November 2021
- Dr V. did not follow up blood results overnight or when he found Colin had left hospital
- Lack of training on Adult Sepsis Pathway and neutropenia guidelines for Dr V. at that time
Coroner's recommendations
- Western Australian Government should allocate appropriate resources to PathWest to fund procurement and deployment of digital microscopy solutions (such as CellaVision) throughout the state to improve timeliness and accuracy of Haematologist review for patients in regional areas
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