Finding into death of Graeme John Jennings

65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rectus sheath haematoma and retroperitoneal bleeding from quad bike trauma)

A 65-year-old man presented with quad bike accident injuries and had markedly elevated inflammatory markers (CRP 329–556, WCC 12.3–18) during his first hospital admission. These were suggestive of developing infection, particularly given contaminated farm soil abrasions to his elbow and knee. Junior surgical staff noted the abnormal results but did not escalate them to the consultant surgeon, Mr Kamenjarin, who did not proactively interrogate pathology findings before discharging the patient as a 'soft tissue injury'. The patient was readmitted four days later with overwhelming staphylococcal sepsis requiring surgery, and died. The Coroner found omissions at each level of the surgical team were causal factors. Intravenous antibiotics initiated during the first admission would likely have prevented death. Key deficiencies included failure to recognise sepsis risk, poor communication of critical results, inadequate consultant oversight, and premature discharge without excluding infection.