Finding into death of MRS M

91y · Female·Complications of pelvic fractures sustained in a fall

A 91-year-old woman with osteoporosis and multiple comorbidities sustained pelvic fractures in a mechanical fall at home. She presented to the ED where initial hip x-ray showed no fracture. She deteriorated with hypotension and was treated with antibiotics for presumed pneumonia. She suffered cardiac arrest shortly after antibiotic administration and died. Post-mortem CT revealed pelvic fractures missed on initial imaging. Key clinical lessons: the initial hip x-ray failed to detect pelvic fractures that contributed to her deterioration; elderly trauma patients with mechanism for pelvic injury warrant high-quality imaging (CT pelvis); the deterioration appeared multifactorial (trauma, anaemia, cardiorespiratory strain) rather than due to antibiotic allergy. Medical records documented previous penicillin 'side effects' (GI upset) rather than true allergy, and the patient and husband correctly reported no allergies. The coroner found care reasonable and appropriate, but highlighted risks of fragmented electronic health records and the benefit of integrated EMR systems.