Coroner's Finding: Powell, Arthur John

90y · Male·Sepsis secondary to wound infection/dehiscence and bilateral parotid gland infection following surgical repair of perforated diverticulum

Arthur John Powell, a 90-year-old with ischaemic heart disease, chronic lung disease, and diabetes, underwent emergency surgical repair of a perforated diverticulum on 1 September 2015. Post-operative recovery was initially good. However, his surgical wound deteriorated from wet (19 September) to 'terrible' (23 September) but was never reviewed by the surgeon and was not treated with antibiotics despite clear infection signs. Mr Powell developed bilateral parotid gland infection and was discharged on 25 September while still infected. He deteriorated at the nursing home and was re-admitted with septic shock, acute kidney injury, and Staphylococcus aureus bacteremia, dying 6 days later. The coroner found the wound management 'ineffective', failure to review the wound 'a poor decision', failure to recognize and treat infection 'regrettable', and discharge while infected 'a poor decision'. Treatment fell short of expected standard. Critical lessons: regular post-operative wound assessment, prompt recognition and treatment of surgical site infections, and appropriate discharge decisions.