Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected bladder biopsy sites with Escherichia coli and Enterococcus faecalis

Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies were performed by an inexperienced registrar, Dr V., under supervision of urologist Mr Robert Thomas. The biopsies were significantly deeper than appropriate, with at least one penetrating into the peritoneal cavity and becoming infected. Critical delays occurred in recognising the deterioration, providing antibiotics, and escalating care. The patient was not reviewed by medical staff for 22 hours post-procedure despite warning signs including fever, abdominal pain, absent urine output, and abnormal bladder scans. When antibiotics were finally ordered at 10am on day two, they were poorly charted and not administered promptly; gentamicin was not given until 6:30pm, over 8 hours later. Mr Thomas failed to attend the hospital despite concerning imaging findings and multiple telephone updates; he was unavailable when finally needed at midnight due to a social engagement at a restaurant with alcohol consumption. The coroner found the death entirely preventable with competent supervision and timely treatment, and referred all three doctors to the Medical Board.