Coroner's Finding: BEGBIE Peter John

41y · Male·multi-organ failure and staphylococcal septicaemia following pulmonary and aortic valve replacement for staphylococcal endocarditis of the aortic valve

A 41-year-old man with a pre-existing aortic valve abnormality developed staphylococcal septicaemia, likely initiated by Q fever exposure at his abattoir workplace or a finger laceration. He presented with fever and chest pain but was initially misdiagnosed as having viral infection. Following appropriate blood tests revealing thrombocytopenia, he was admitted to RAH. He absconded after 24 hours, returning to the community in a delirious state due to sepsis-induced acute organic brain syndrome. He was appropriately detained under the Mental Health Act to ensure treatment, re-admitted to RAH, and underwent emergency aortic and pulmonary valve replacement. Despite technically successful surgery, he suffered extensive myocardial infarction, multi-organ failure and died. Clinical lessons: early recognition of sepsis severity, appropriate use of mental health legislation for acute delirium secondary to medical illness, and timely escalation to cardiothoracic surgery. Vaccination of at-risk workers with pre-existing cardiac pathology warrants consideration.