Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 11:41am onwards, indicating bacterial infection. Despite fulfilling sepsis criteria and showing haemodynamic deterioration from 3:30pm with hypotension (86/54) consistent with septic shock, antibiotics were not commenced until 7:20pm. She died at 9:25pm. Multiple failures occurred: her GPs did not administer recommended Pneumovax23 vaccination (she was Aboriginal, age 57); the ED failed to recognise sepsis despite clear indicators; and critical handover between ED and ward at 3:30pm lacked specificity, resulting in failure to escalate or initiate antibiotics until cardiac arrest was imminent. Earlier antibiotic therapy (by midday-3:30pm) would likely have saved her life.