Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for the management of sepsis due to an infected foot ulcer requiring above-the-knee amputation in a man with type 2 diabetes mellitus

Christopher McIntosh, a 54-year-old man with type 2 diabetes, died from respiratory failure secondary to sepsis originating from an infected foot ulcer while incarcerated at Hopkins Correctional Centre. The coroner found that while overall care was reasonable and appropriate, significant missed opportunities existed in wound management. McIntosh was never formally trained in wound care despite self-managing dressings; health staff failed to monitor regularly (2-week gap before acute deterioration); specialist referrals were delayed; and documentation was poor. When acute sepsis with spreading necrosis developed on 4 April 2022, staff appropriately recommended hospital transfer. Although McIntosh initially refused and requested a 2-day delay for NDIS matters, the vascular surgeon concluded that earlier transfer would likely not have prevented amputation or death. Recommendations addressed developing wound management pathways, improving patient education and documentation, and establishing regular monitoring protocols.