Finding into death of John Miklosowa

38y · Male·Urosepsis

John Miklosowa, a 38-year-old man with Down syndrome and severe intellectual disability, died from urosepsis after rapid deterioration at his residential facility on 28 March 2009. He had a permanent suprapubic catheter inserted in 2008 for chronic urinary retention and had experienced ongoing problems with catheter dysfunction and leakage. On 28 March, after a routine catheter change by Royal District Nursing Service, the catheter began bypassing. He deteriorated rapidly that afternoon with fever, tachypnoea and hypoxia, presenting to hospital in septic shock requiring intensive care. Despite aggressive treatment including mechanical ventilation, he developed hypoxic brain injury and died 12 days later. The coroner found his care was appropriate and found no evidence of preventable errors, though the sudden clinical deterioration in the setting of chronic catheter problems was the critical event.