Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective endocarditis)

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with recurrent sepsis and died. Autopsy revealed infective endocarditis of the tricuspid valve with myocarditis. The coroner identified two key issues: (1) infective endocarditis was not considered as a differential diagnosis during the first admission, though expert evidence indicated this diagnosis was very difficult without positive blood cultures or typical clinical signs; and (2) critical communication failures—the discharge summary was not completed until the day after her death, and her general practitioner never received it. The patient presented to her GP three times post-discharge with ongoing abdominal pain and palpitations but received no clear guidance. Had the GP received timely discharge documentation, earlier re-referral to hospital might have provided a higher chance of survival, though prognosis remained poor.