Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left shoulder on a background of congestive cardiac failure

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate medical care, a critical medication error occurred when Mr Wilson was transferred to Port Augusta Prison: newly prescribed cardiovascular medications (bisoprolol and digoxin) were not documented on his medication chart, and he did not receive them. The Queen Elizabeth Hospital discharge summary identified this medication error as the 'trigger' for his decompensated heart failure requiring ICU admission. Although the error was significant and required emergency retrieval and intensive care, the coroner found it did not cause or significantly contribute to his ultimate death. The case highlights the importance of medication reconciliation during prisoner transfers between facilities, particularly for complex cardiac patients.