Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23 August 2017 with aspiration pneumonia and displayed aggressive behaviour necessitating an Inpatient Treatment Order. On 6 September, her condition deteriorated rapidly with sepsis, requiring ICU admission and intubation. During treatment, an Acomed infusion pump failed silently, temporarily compromising noradrenaline delivery when her blood pressure was critically low (60 mmHg systolic). Despite manual administration resumption and maximal vasopressor support, she arrested at 7:06 am on 7 September. A review panel concluded the pump failure did not contribute to death, as her underlying cardiac dysfunction and septic shock were the primary cause. The coroner found detention lawful, care appropriate, and no recommendations were warranted.