Finding into death of Graeme William Dimsey

62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of status post fractured neck of femur and Girdlestone procedure

A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months post-knee replacement. Despite clinical suspicion of prosthetic joint infection, the orthopaedic team repeatedly decided against joint aspiration, citing concerns about introducing infection—a concern the coroner found unreasonable given he was already on antibiotics with negative blood cultures. The team also failed to diagnose a hip fracture after he fell from his bed. Intellectual disability and delirium complicated assessment, but the coroner found the death preventable because earlier aspiration and diagnosis would likely have altered outcomes. Key failures included: not performing the planned aspiration despite no alternative infection source, inadequate multidisciplinary consultation, and delayed hip fracture diagnosis. The coroner found empirical evidence shows joint aspiration carries minimal infection risk (0.037-0.08%) and is far outweighed by risks of missing septic arthritis.