Coroner's Finding: Handasyde, Robert Neil

86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney infection) and focal areas of infection in the prostate gland

An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and nocturia, suggesting bladder neck obstruction. This diagnosis was missed by the GP and subsequently by hospital staff during an April admission for rectal bleeding. The obstruction led to urinary retention, infection of retained urine, and fatal sepsis. Timely urological assessment and catheterisation or surgery would likely have prevented death. Critical failures included: incomplete history-taking, failure to diagnose bladder obstruction despite clear clinical indicators, inappropriate oral antibiotic monotherapy for septic shock (requiring IV antibiotics and hospital admission), and excessive opioid dosing causing toxicity in a patient with renal impairment. The nursing home should have escalated to hospital when the GP failed to attend on 19 June despite signs of septic shock.