Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; contributing factors emphysematous pyelitis and candidaemia

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming kidney infection). Despite clear warning signs of developing sepsis over 19 hours—including progressive falls in diastolic blood pressure, widening pulse pressure, tachycardia, and family concerns—no escalation to medical review occurred until a MET call at 7:47pm when blood pressure fell to 86/54. Critically, IV fluids were not initiated until the MET call, despite her being a vomiting diabetic with serious infection. She deteriorated into septic shock, required ICU admission, and died on 26 June 2024 from urosepsis with multi-organ failure. The coroner identified multiple missed opportunities for earlier recognition and intervention. Eastern Health accepted the finding as a Sentinel Event and implemented system improvements.