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Assessment and management of sepsis resulting in death (06HDC08129)

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(06HDC08129, 17 September 2007)

General surgeon ~ Public hospital ~ Intensive care team ~ Sepsis ~ Standards of care and communication ~ Right 5(1)

A 27-year-old woman was admitted to a provincial public hospital emergency department at about 10am with a three-day history of increasingly severe abdominal pain. She was assessed by the surgical registrar, who made a provisional diagnosis of peritonitis secondary to pelvic inflammatory disease. Shortly after diagnostic X-rays were performed at 2pm, the woman deteriorated rapidly. A general surgeon reviewed the woman and organised an urgent transfer to theatre for exploratory laparoscopic surgery, which revealed extensive infection of the Fallopian tubes (salpingitis) and pus in the peritoneal cavity. A gynaecologist was called in to advise on treatment. During the surgery, the anaesthetist was concerned about the woman's condition and transferred her to the intensive care unit for postoperative monitoring.

Her condition continued to cause concern during the night. She was reviewed at 2am, and at 7am it was decided that more invasive measures were needed to stabilise her. However, as these measures were being implemented, she suffered a cardiac arrest, was unable to be resuscitated and died. The circumstances of her illness and death were briefly outlined to the family before they left the hospital.

Despite several attempts, the family was not contacted until a month later when a meeting was offered to explain the circumstances of the woman's death. This offer was declined. The Coroner's report was made available to the family the following day. The family was concerned that the results of the post mortem differed from the information provided by hospital staff about the woman's illness.

It was held that the woman received care of an appropriate standard from the surgeon and the public hospital, but that the hospital failed to communicate effectively with the family - at the time of her admission to ICU, when her condition deteriorated overnight, and after her death - and breached Right 5(1).