Finding into death of Lynsie Maree Everett

36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respiratory failure secondary to community-acquired pneumonia with ruptured pulmonary bulla

A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators of severity including hypotension, tachypnoea, and hypoxia. Critical failures included: inadequate appreciation of sepsis severity; failure to escalate to ICU consultation or retrieval services; insufficient IV fluid resuscitation (patient encouraged to refuse); misinterpretation of respiratory distress as anxiety/alcohol withdrawal; sparse overnight vital sign monitoring despite clinical deterioration; and inadequate resuscitation with no advanced airway management available. The patient deteriorated overnight with progressive hypoxia, received only basic airway support, and collapsed at 3:20am. Resuscitation was unsuccessful; a MET code (rather than Code Blue) was called with no doctor present having advanced airway skills. Death resulted from respiratory failure due to pneumonia with ruptured pulmonary bulla.