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VIChospital2022-08-29

Finding into death of Helen Welsh

63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities

…rge day, she deteriorated with fever, altered consciousness, and hypotension. A MET call was initiated and sepsis was suspected. However, clinical staff prioritised CT imaging over immediate antibiotic administration whi…

cardiothoracic surgeryemergency medicinedelaydiagnosticcarbimazole
VIChospital2010-03-22

Finding into death of Magdalena Schauer

36y · Female·Acute brain injury due to intracerebral haemorrhage secondary to sepsis

…s and purpuric rash. Paramedics appropriately administered empiric antibiotics for suspected meningococcal sepsis. Hospital investigation revealed intracerebral haemorrhages and blood cultures grew Staphylococcus aureus …

emergency medicineintensive careheroin
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum …

obstetricsemergency medicinediagnosticcommunicationparacetamol
NSWhospital2025-05-28

Inquest into the Death of Garry Small

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

…iabetes, 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 charte…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
ACThospital2023-01-30

Inquest into the Death of Maarouf El-Cheikh

57y · Male·streptococcus pneumonia septicaemia due to splenectomy

Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: …

emergency medicineintensive carediagnosticmedicationceftriaxone
TAShospital2024-07-25

Coroner's Finding: Briffa, Gennette Anne

73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…

A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surg…

bariatric surgerygeneral surgerydiagnosticdelayapixaban
NThospital2019-09-20

Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

…ine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 11:41am onwards, indicating bacterial infection. Despite fulfillin…

emergency medicinegeneral practicediagnosticcommunicationondansetron
VIChospital2025-08-22

Finding into death of Melanie Ranken

33y · Female·Respiratory sepsis in a woman with an acquired brain injury

…cquired brain injury from a 2017 motor vehicle accident and post-traumatic epilepsy, died from respiratory sepsis secondary to community-acquired pneumonia. She was admitted to Ballarat Base Hospital on 20 May 2025 with …

respiratory medicineinfectious diseases
TAShospital2014-09-19

Coroner's Finding: Tetley, Barry Lindsay

72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)

…77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these findings, he was discharged without vital signs being rechecked or documented, without exam…

emergency medicineintensive carediagnosticcommunication
NSWhospital2020-03-17

Inquest into the death of Esteban FRANCO-GARCES

11y · Male·Sepsis

…d premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures included: delayed …

emergency medicinepaediatricsdiagnosticdelayantibiotics
TAShospital2021-04-12

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: e…

urologysurgerydiagnosticmedicationcefazolin
TAShospital2019-04-16

Coroner's Finding: Hill, Phillip John

82y · Male·sepsis due to faecal peritonitis due to suture failure of bowel anastomosis foll…

An 82-year-old man died from sepsis due to faecal peritonitis following anastomotic breakdown after right hemi-colectomy for colon cancer. Sur…

colorectal surgerygeneral surgerydelayamiodarone
VIChospital2026-05-04

Finding into death of Baby E

3y · Female·COMPLICATIONS FROM SEVERE CEREBRAL PALSY

…m complications of her severe cerebral palsy. She presented with seizures, dark green sputum, and signs of sepsis (respiratory acidosis confirmed). Despite treatment for presumed chest sepsis and non-invasive ventilation…

intensive carepaediatrics
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) wi…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
QLDhospital2015-07-27

KS - Non-inquest findings

69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…

…nd cardiac history, administering aspirin, clopidogrel and enoxaparin. However, the patient had concurrent sepsis (Staphylococcus aureus bacteraemia) from a recurrent spinal infection. At the metropolitan hospital, sepsi…

emergency medicinecardiologydiagnosticmedicationrivaroxaban
VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

…harged with advice to see her GP in one week. She returned on 24 January 2024 hypoxic and hypotensive with sepsis, requiring ICU admission. Despite treatment with antibiotics and supportive care, she deteriorated from se…

emergency medicineintensive carediagnosticdelayceftriaxone
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

…tional radiologist failed to appreciate the significance of the prior Whipple procedure and its associated sepsis risk. Prophylactic antibiotics (ciprofloxacin and metronidazole) before, during and after SIRT would likel…

radiologyemergency medicinediagnosticmedication
TAShospital2021-02-03

Coroner's Finding: Boon Alison Kim

51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…

A 51-year-old woman with intellectual disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via…

general surgerycolorectal surgerydiagnostic
VIChospital2011-07-13

Finding into death of Nuray Yurekturk

39y · Female·Sepsis and renal failure secondary to a perinephric abscess

…phric abscess detected when staff noticed a raised area on her lower back. She presented to hospital where sepsis and acute kidney failure were identified. Despite drainage of the abscess and supportive care, her conditi…

urologyemergency medicine
VIChospital2010-12-08

Finding into death of Peter Greenhill

57y · Male·Sepsis and acute renal failure due to pneumonia

…pital with chest pain, breathing difficulty, atrial fibrillation, and hypoxia. He was diagnosed with chest sepsis, septic shock, respiratory failure, and acute renal failure. Despite ICU admission and treatment with anti…

intensive caregeneral medicineantibiotics
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