Inquest into the Death of Anna Maria WINTER

94y · Female·Sepsis complicating management of vulval carcinoma in an elderly woman with severe coronary artery atherosclerosis, originating from spontaneous rupture of a sigmoid diverticulum

A 94-year-old woman with vulval carcinoma underwent suprapubic catheter insertion at a private hospital on 14 May 2014. She appeared well post-procedure with normal observations. The following day, she was transferred by taxi (rather than ambulance) to a tertiary hospital for oncology review. On arrival, she collapsed with septic shock and died 5 days later from sepsis. Post-mortem and expert review concluded the sepsis resulted from spontaneous rupture of a sigmoid diverticulum into the peritoneal cavity, unrelated to the catheter procedure. Clinical lessons: (1) ensure clear documentation of transfer plans and appropriate transport method; (2) recognise that a seemingly well post-procedure patient can deteriorate rapidly from non-iatrogenic causes; (3) communicate clinical concerns and arrangements clearly between facilities. The transfer by taxi was a genuine error but did not contribute to the fatal outcome.