Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation therapy

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxone ordered but not charted at 1:00pm, flucloxacillin not given until 6:04pm, and ampicillin withheld due to ED unavailability. Management deviated from the Sepsis Pathway with inadequate repeat observations and lactate monitoring. He developed delirium (multifactorial: sepsis, medications including oxycodone 10mg and diazepam, frailty) and fell unwitnessed on day 2, sustaining a subdural haematoma requiring surgery. Although care was suboptimal, the coroner found the fall's cause multifactorial and could not conclude that timely antibiotics would have prevented it or materially altered the outcome.