Inquest into the death of Pauline KESSELL

53y · Female·multiple organ failure as a result of septic shock

Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1) the surgeon should have recognised this as an infection stone requiring percutaneous nephrolithotomy rather than prolonged endoscopic manipulation, which created high intrarenal pressures leading to bacteraemia and endotoxin release; (2) no pre-operative antibiotic prophylaxis was documented despite positive urine culture; (3) the anaesthetist was not alerted to sepsis risk and could not leave theatre to review deteriorating patient; (4) nursing staff struggled to escalate concerns without specific criteria; (5) antibiotic administration in critical post-operative period was poorly coordinated with confusion over clinical responsibility. European and American guidelines recommend percutaneous nephrolithotomy for stones >2cm; the surgeon had not previously used endoscopy for stones >3cm.