Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left antecubital fossa intravenous access site puncture wound

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours before hospital admission, but hospital staff failed to remove it within the required 24-hour protocol window. The site became infected with purulent discharge noted on day 5. Clinical lessons include: strict adherence to PIVC removal protocols is essential to prevent catheter-related infections; field-inserted lines require clear identification and monitoring handover; and responsibility assignments must be explicit to prevent oversight. The coroner found this preventable death occurred due to lack of identifying markers on the emergency line, absence of documented monitoring, and unclear protocol responsibility allocation.