Coroner's Finding: de-identified BE

85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abscess extending to the base of the right lobe of the prostate gland

An 85-year-old man with dementia and multiple comorbidities died of sepsis caused by an infected sacral pressure ulcer that developed and deteriorated while resident at an aged care facility. Initially assessed as stage 1/healed on admission, the pressure sore progressively worsened despite preventive measures. Critical failures in clinical management included: a delayed referral to wound care specialist (referred late October, reviewed only late November—a month later), inadequate pain relief despite a severe wound, inconsistent wound dressing documentation, and recurrent faecal contamination of dressings due to inadequate continence management. The facility's electronic records system may not have accurately reflected care provided. The coroner found that escalation to specialist review and more aggressive management strategies were warranted but did not occur. By the time specialist review occurred, the wound was extensive (stage 3/4) and infected. The patient developed fever and sepsis, requiring hospital admission where he transitioned to palliative care and died. Better wound management protocols, timely specialist referral, pain relief provision, and clearer documentation could have prevented this deterioration.