Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hypertensive heart disease and morbid obesity

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive of sepsis (6-day UTI symptoms, rigors, confusion). The ED RMO assessed the patient as having a simple UTI and discharged him with oral antibiotics after an hour. The patient died at home that night from urosepsis (E. coli bacteraemia). The coroner found the death preventable: the paramedic clinical record contained clear sepsis warning signs that should have triggered the hospital's sepsis pathway and IV antibiotic administration. Key failures included incomplete review of paramedic observations, inadequate communication of critical information to the senior doctor consulted, and failure to follow the existing sepsis protocol despite documented risk factors.