Coroner's Finding: BROADWAY Rita Ann

66y · Female·urinary tract infection with contributing hypertensive heart disease, diabetes mellitus and bladder catheterisation

Rita Ann Broadway, 66, died from urinary tract infection on 2 January 2015, one day after presenting to Modbury Hospital Emergency Department with vaginal pain and signs of infection. She had a long-term indwelling catheter placed for urinary incontinence. The ED doctor did not recognize catheter-associated urinary tract infection (CAUTI) despite key clinical indicators: abnormally low temperature (35.5°C), acute pelvic pain, and urinalysis positive for leucocytes, nitrites, and protein. The SAAS paramedics' report documenting catheter 'flooding' was not integrated into clinical decision-making. The doctor declined her explicit request for catheter change. Expert evidence concluded that if the catheter had been changed and antibiotics given, her survival chances would have exceeded 80-90%. The following morning, RDNS declined her repeated request for catheter change, appearing not to recognize ongoing infection. The death was potentially preventable with appropriate recognition and management of CAUTI.