FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking percutaneous endoscopic gastrostomy (PEG) tube in the context of oculopharyngeal muscular dystrophy

A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharge with fever, nausea, vomiting and abdominal pain. Critical failures included: failure to recognise sepsis despite elevated lactate (2.98), elevated WCC and CRP; delayed antibiotic administration (6 hours); failure to escalate hypotension on 1 March; inadequate PEG complication guidance in rural settings; delayed surgical team acceptance (insisted on formal CT report); and transfer by single paramedic with nurse escort without RSQ consultation despite clinical instability. She arrested during ambulance transfer and died. Early recognition of sepsis, appropriate escalation, and consultation with retrieval services could have improved outcomes.