Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis due to infected foot ulcer requiring above-knee amputation in a man with diabetes mellitus

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarcerated at Hopkins Correctional Centre when his condition deteriorated. Critical clinical lessons include: (1) patients with chronic diabetic ulcers refusing treatment require enhanced vigilance and structured monitoring; (2) wound care management must include documented patient education even when patients insist on self-care; (3) absence of documented follow-up on specialist referrals (podiatrist, high-risk foot team) represents a significant care gap; (4) poor record-keeping and lack of formalized wound assessment tools compromised care continuity. While McIntosh declined hospitalization for personal reasons (NDIS funding, prison transfer concerns), the coroner found no evidence that earlier transfer would have changed outcome, though specialist opinion noted the infection was substantially more severe by admission. Key preventive measures: implement structured wound management pathways, ensure documented patient education, maintain rigorous follow-up on specialist recommendations, and improve record-keeping systems.