This inquiry considered the failure of primary care providers to offer the Pnemovax23 vaccination to a vulnerable individual, and the failure by the Katherine Hospital to identify sepsis and septic shock.

Background

The Deceased, Joanne Craig, was a 57 year old woman of Aboriginal descent from the Wurrumumga clan group. The Deceased attended various medical clinics in the past, attending the Wurli-Wurlinjang Health Service in Katherine between 2009 and November 2017, the Kintore Clinic in Katherine (later taken over by the Gorge Health Services) from 2010 and September 2016, and a further four attendances at the Central Clinic Alice Springs from 2004 to 11 January 2018. On 23 January 2018, the Deceased was having dinner with her husband when she complained of 'feeling cold and feverish.' As the Deceased did not show signs of improvement, the next morning the Deceased was driven to the Emergency Department of the Katherine District Hospital, and was triaged at 9.12am. The working diagnosis for the Deceased was a likely viral illness with no clear source of infection. The Deceased deteriorated throughout the day, went into cardiac arrest at 8.42pm and was declared life extinct at 9.25pm. The Deceased died due to multiple organ failure caused by sepsis that was due to a streptococcus pneumoniae infection. For streptococcus pneumoniae, the very young and the elderly are at risk, and Aboriginal and Torres Strait Islander people in particular lack immunity to encapsulated bacteria. However, streptococcus pneumoniae is a vaccine preventable disease.

Findings

The Coroner detailed that there were three General Practices that the Deceased utilised after the age of 50, being the Central Clinic in Alice Springs, Kintore Clinic/Gorge Health Services in Katherine and Wurli-Wurlinjang Health Service in Katherine. The Central Clinic only saw the Deceased on two occasions, both of which were focused on her blood pressure. The Wurli-Wurlinjang Health Service saw the Deceased on multiple occasions, both prior to the Deceased turning 50 and then afterwards for numerous reasons. When asked by the Coroner's office why the Deceased had not received the vaccination, the Health Service stated that there was no vaccination schedule for the pneumovox23, and that eligibility for the vaccination would only be prompted during an Aboriginal Health Assessments, which were offered annually to those who identified the Service as their primary health clinic, which the Deceased had not done. During the inquest the Senior Medical Officer said that 'it was probably an… oversight that she was not offered an Aboriginal and Torres Strait Islander health check at that time.' The third practice stated that they could not find the Deceased's medical notes from any consultation with the Kintore Clinic prior to being taken over by Gorge Health Services. However, Gorge Health Services showed four instances when the Deceased had visited, and when asked questions on vaccination, the Service responded by indicated that Wurli-Wurlinjang Health Service was her primary health clinic for 'at least a year before her death.' The Coroner concluded that the Deceased was neither provided the vaccine nor provided any information in relation to it by any of the General Practice she had attended. The Deceased's hospital treatment was also critically evaluated by the Coroner. The Coroner believed that it was apparent when initially arriving at Katherine Hospital that she was suffering from sepsis, with the only treatment for sepsis being the administration of broad spectrum antibiotics early. The expert medical opinions were split on the latest time antibiotics could have been given, with one expert believing midday at the latest, and the other opining that shortly after 3.30pm was when the Deceased should have had the antibiotics.

On arrival, the impression of the doctors was that the Deceased was suffering from a likely viral illness, and it was said that she had entered the sepsis recognition pathway. Over the course of a day, the Deceased was monitored and fluctuated between seemingly improving and deteriorating, until antibiotics were given at 7.20pm which at that time was too late. The Coroner criticised the documentation and the lack handover between the Emergency Department practitioners and Ward practitioners. However, since the Deceased's death, there were multiple steps taken by the hospital, Top End Health Service and the Department of Health to improve training, recognition of sepsis, processes and documentation to which the Coroner commended.

In his comments, the Coroner noted that, despite two inquests into the failure to identify sepsis at a Northern Territory Hospital, the need for early intervention seemed not to have been appropriately understood. Further, the Coroner stated that in this case the death of the Deceased was likely to have been preventable.

Recommendations

The Coroner made four recommendations following consideration of Joanne Craig's death, being:

  1. that General Practitioners have a schedule for and make every effort to provide to Aboriginal and Torres Strait Islander people the Pheumovax23 (23vPPV) vaccination in accordance with the Australian Immunisation handbook.
  2. that the Top End Health Service do all things necessary to ensure its staff are competent in the recognition of sepsis and escalation of treatment and that such efforts are ongoing.
  3. that the Top End Health Service do all things necessary to ensure that the documentation utilised when treating patients is appropriate and appropriately utilised.
  4. That documentation utilised be audited on a regular basis.