Simons, Kathleen

96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by multiple organ failure

A 96-year-old woman with diabetes, dementia and a chronic blistering skin condition developed progressively worsening leg ulcers with exposed tendons while resident in an aged care facility. Despite multiple medical reviews between February and June 2015, the wounds were not escalated to hospital care. A tendon was identified as exposed in late April 2015, requiring specialist intervention, yet conservative dressing continued. An out-of-hours GP provided minimal intervention; the regular GP documented inadequate notes and made no wound swabs or hospital referrals despite clear deterioration. A 'wound care specialist' consulted in May was not a registered nurse and her involvement was poorly documented. The patient was admitted to hospital only in June 2015 with advanced sepsis from pseudomonas infection in the leg ulcers; she died three days later. The coroner found inadequate wound assessment and documentation by nursing staff, failure of the visiting GP to escalate care or refer appropriately, insufficient communication with family, and lack of due diligence in credentialing external consultants.