Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip in an elderly lady with complex chronic heart disease and chronic renal impairment

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Key clinical lessons: (1) Admission urinalysis was not performed despite high UTI risk in elderly females; cloudy urine postoperatively suggested possible E. coli infection from catheter. (2) Single perioperative antibiotic dose (Keflin) was inadequate; infection risk appeared unrecognized. (3) Vitamin K reversal of Warfarin was suboptimal—a missed overnight second dose (17-18 Nov) reflected inadequate night medical cover. (4) Postoperative deterioration from day 2 (hypotension, rising CRP, loose stools) should have triggered earlier sepsis recognition. (5) Underlying cardiac vulnerability and developing sepsis created cumulative insult; aggressive fluid management aimed at hypotension may have contributed to pulmonary/cardiac fluid overload evident at autopsy. (6) Pressure sores developed rapidly preoperatively and remained painful. The case illustrates that elderly patients with borderline organ reserve require close monitoring, lower threshold for infection suspicion, and protocolized perioperative care.