Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the setting of urosepsis

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ridge Multi-Purpose Centre despite clinical features (severe vomiting, abdominal pain, elevated temperature) warranting transfer to Dubbo Base Hospital for CT imaging to exclude serious differential diagnoses. Critical failures included: (1) failure to document and investigate differential diagnoses (bowel obstruction, pancreatitis, diverticulitis); (2) no vital signs recorded for 12 hours despite yellow-zone temperature; (3) failure of on-call doctor to attend when called about deteriorating patient; (4) no consultation with senior clinician before admission decision. Experts unanimously agreed it was "more probable than not" Eve would have survived had she been transferred the previous evening. The coroner found the death potentially preventable through early consultation, proper diagnostic reasoning, and timely transfer to a facility with imaging and surgical capacity.