Coroner's Finding: Davis, Graeme Charles

56y · Male·sepsis

A 56-year-old man died from sepsis following elective bladder cancer surgery. Post-operative infection developed with clear clinical signs: elevated CRP (205-284 mg/L), positive bacterial cultures (Staphylococcus aureus, Klebsiella pneumoniae), fever, wound drainage, and systemic symptoms from 16 January onwards. Despite obvious infection markers from 20 January, antibiotics were not commenced until 25 January—five days later and too late. The surgical team attributed the wound appearance to non-infectious causes and failed to recognise sepsis severity. Antibiotic administration was also delayed once prescribed. The coroner found this death entirely avoidable, caused by failure to diagnose infection, failure to initiate timely antibiotics despite clear laboratory evidence, and subsequent delays in administration. Early recognition of sepsis signs and prompt antibiotic therapy would likely have prevented death.