Inquest into the death of Maureen Smith

75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis

A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropriately identified possible septic arthritis and contacted orthopaedic registrar Dr N., who advised withholding antibiotics pending joint aspiration at Armidale Rural Referral Hospital. However, critical delays occurred: a non-emergency transport booking was made, then transferred to NSW Ambulance around 3.15pm. At 5.07pm, ambulance crew declined transfer citing resource constraints, advising the patient would go "tomorrow". Dr M. and nursing staff failed to adequately escalate or insist on urgent transfer. The patient remained at Glen Innes overnight without appropriate observations or antibiotics. On 1 April, increasing confusion was noted ("off with the fairies") but not recognised as sepsis marker. Transport was rebooked but delayed further. By arrival at ARRH at 3.14pm, the patient was in shock and died shortly after. Key failures: failure to recognise and escalate sepsis signs (delirium); inappropriate advice to withhold antibiotics once same-day transfer became impossible; breakdown in inter-hospital transfer coordination with excessive focus on "between-the-flags" status; and inadequate nursing observations overnight.