Finding into death of Ellen Plymin

85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)

Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound swabs revealed MRSA infection. Her GP, Dr M., consulted a microbiologist and arranged topical betadine dressings, believing the infection was superficial. The family requested hospital admission on 1 June, but Dr M. refused. By 4 June, the wound deteriorated with brown ooze and offensive odour; Dr M. interpreted this as beneficial drainage. She was finally readmitted 6 June, when deep joint infection was discovered. Multiple surgical interventions followed. She died 27 June from sepsis with cardiac and respiratory complications. The coroner identified a diagnostic error in misinterpreting a deep joint infection as superficial, but found the decision to manage at aged care was 'not necessarily unreasonable' given specialist consultation and her complex medical history.