Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of Christine Anne INCHES

Find That:

(a) The identity of the deceased is Christine Anne Inches ('Mrs Inches');  

(b) Mrs Inches died on 6 February 2013 in New Norfolk;

(c) Mrs Inches was born in Hobart on 16 April 1953 and;

(d) She died as a result of sepsis complicating acute peritonitis arising in the setting of extensive diverticular disease of the sigmoid colon. Significant contributing factors were aspiration of gastric contents and hypertensive heart disease.

Circumstances Surrounding the Death:

Mrs Inches was a 59 year old resident of New Norfolk. She had suffered cervical cancer which was successfully treated in 2009. Her current medical history included hypertension and depression which were being managed with medication.

Mrs Inches became unwell in the early evening of 5 February 2013. She called Ambulance Tasmania and the attending paramedic recorded the visit in these terms:

"Patient not used bowels for past 2 days. Normally has an active bowel and takes lomotil. Patient became quite anxious whilst trying to use her bowels and not being successful. Began to hyperventilate, creating tingling in hands and feet and mild nausea. On arrival and examination-patient still symptomatic of hyperventilation symptoms but had settled somewhat. Patient was oriented to time, person and place, GCS 15, all vital signs within normal limits at 18:55. Advised to call back if she changed her mind or if concerned or if new symptoms present. Patient left in the care of her son and his girlfriend."

The ambulance crew left Mrs Inches' home at 7.44pm. However, Mrs Inches called Ambulance Tasmania again about one hour later and a crew arrived at her home at 8.58pm. Mrs Inches told them that she had abdominal pain which had commenced after eating a meal of chicken. She said that she had commenced vomiting after eating the meal and that she had had multiple episodes of diarrhoea. The paramedics assessed Mrs Inches as very anxious, hyperventilating, febrile (her temperature was 39.6 degrees centigrade) and tachycardic. She rated her pain as 7 out of 10 and was administered Penthrane via a patient-held whistle device. This dropped her pain level to a self-stated 5 out of 10. Mrs Inches was then transported to the Hobart Private Hospital ("the Private").

Mrs Inches arrived at the Private's Emergency Department at 10:40pm. Clinical observations made on arrival were: temperature 39.8 degrees centigrade, pulse 140 beats per minute, blood pressure 123/73, oxygen saturation 96% on room air, Glasgow coma score (GCS) 14/15. Pain level was rated 8 out of 10. Her respiration was described as slow and grunting although the primary triage sheet recorded her respiration as rapid.

Mrs Inches was promptly seen by Dr Paul Dudgeon. She told him that she had abdominal pain which she described as cramping in nature. She also said that she had vomited and had had diarrhoea. He recorded that she had abdominal pain bilaterally with mild voluntary guarding but with no rebound tenderness. He noted that she was a poor historian, would not make eye contact with him and the answers she provided to his questions were described as "delayed." He considered this behaviour unusual and may be due to pain and delirium, a transient state secondary to high fever and Penthrane. He ordered blood tests and directed that Mrs Inches be administered anti-emetic and anti-spasmodic medication along with a litre of intravenous fluid. At this stage Dr Dudgeon was "very concerned for her health" and suspected that Mrs Inches would require admission to hospital. He therefore ensured that her blood results were copied to general surgeon, Mr S Wilkinson. Five milligrams of morphine was also administered as well as intravenous paracetamol. At this point Dr Dudgeon's working diagnosis was viral gastroenteritis with a secondary diagnosis of delirium secondary to high fever. However, he says he had not "ruled out" sepsis as a diagnosis.

Mrs Inches' blood results showed decreased levels of potassium (3.3, - normal = 3.5 to 5), magnesium (0.47, - normal = 0.70 - 1.05) and phosphate (0.31, - normal = 0.80 - 1.45). She was thus given oral magnesium and potassium supplements. Her white cell count was below normal (3.1, - normal = 3.5 - 11.0) with a left shift and vacuolation. Her CRP (C - Reactive Protein) was 7.9, (within normal limits). The bilirubin level was elevated as was the anion gap.

At about 11:45pm Mrs Inches was incontinent of faeces. She showered and dressed herself with minimal assistance. She was noted about 30 minutes later to be more alert and reported that she was feeling much better. Both she and her family members were keen for her to go home.

Dr Dudgeon reports that he was surprised how well Mrs Inches had responded to her treatment. He considered the blood results and comments; "The results were inconsistent with sepsis which is generally associated with a high C-reactive protein level and white cell count outside the normal range." His interpretation of these results coupled with Mrs Inches' "remarkably" improved clinical condition were, in his view, inconsistent with sepsis and led him to rule it out as the diagnosis. He then permitted her to be discharged from the Private with the direction that she should return if her condition changed or did not improve. This was at 1:00am on 6 February 2013.

Shortly prior to her discharge a second set of clinical observations were made and recorded by Nurse Susan Jones. They showed a pulse of 115 bpm, blood pressure of ~135/85 and a 0/10 pain score. A temperature reading was not recorded. As to its absence Nurse Jones states; "I would normally take a temperature reading at the same time as taking other observations and should have done so on this occasion."

Dr Dudgeon says that he did not review Mrs Inches' final observations. Had he done so he says that it would not have changed his diagnosis or her management. He has noted; "a raised temperature and heart rate are consistent with this diagnosis (of gastroenteritis)."

At 9:58am on 6 February 2013 Mrs Inches' son called for an ambulance to attend at his mother's home. An ambulance was diverted from another call and it arrived at the scene at 10:13am. Mrs Inches was found in a semi-sitting position in the hallway. She was unresponsive. CPR had not been commenced. Paramedics began resuscitative procedures and these were maintained until 10:48am. However, Mrs Inches could not be recovered and she was determined to be deceased.

Post-Mortem Examination:

This was carried out by Forensic Pathologist, Dr Donald Ritchey. In his opinion the cause of Mrs Inches' death was probable sepsis complicating acute peritonitis arising in the setting of extensive diverticular disease of the sigmoid. Significant contributing factors were aspiration of gastric contents and hypertensive heart disease. Dr Ritchey's report includes this comment:

"The autopsy revealed copious purulent fluid (pus) within the abdomen (peritonitis). Although a specific source of peritonitis was not identified at autopsy there were extensive colonic diverticuli which are a likely source. Diverticuli are small pouches of colon that protrude through the muscular wall of the colon and contain impacted faeces. They are associated with long standing constipation. Frequently impacted diverticuli can become infected and may perforate causing widespread infection of the peritoneum (peritonitis). Individuals with acute peritonitis are at risk of developing sepsis - a bacterial infection of the blood."


  • The obtaining of an affidavit from Ms Krystle Lee Wyatt, the daughter of Mrs Inches and the consideration of some correspondence also provided by Ms Wyatt,
  • Receipt and consideration of reports provided by Ambulance Tasmania,
  • An inspection of the Private's hospital records and related correspondence undertaken by Research Nurse, Mrs Libby Newman,
  • The obtaining and consideration of reports provided by Dr Dudgeon,
  • The obtaining and consideration of reports provided by Nurse Jones,
  • Consideration of a report co-provided by the Private's General Manager and Director of Nursing,
  • An assessment of Mrs Inches' medical management carried out by Dr A J Bell in his capacity as medical adviser to the coroner,
  • Receipt and consideration of correspondence received by Simmons Wolfhagen, the solicitors for Dr Dudgeon; and
  • Meetings attended by myself as coroner, Dr Bell, Mrs Newman and forensic pathologists, Drs Lawrence and Ritchey for review and particular consideration of those medical issues related to Mrs Inches' death.

This coronial investigation has included the following:


The focus of my investigation has been Mrs Inches' management by the Private and in particular the failure to diagnose her sepsis and its decision to permit her discharge.

In his advice to myself Dr Bell acknowledges that gastroenteritis and sepsis are illnesses which, in some cases, can be difficult to distinguish as nausea, vomiting, diarrhoea and fever are features which can present in both. Nevertheless, in this instance Dr Bell advises that there were features of Mrs Inches' presentation which should have led Dr Dudgeon to make the diagnosis of sepsis. He points to these matters:

  • A temperature recorded at 39.8 degrees centigrade is inconsistent with viral gastroenteritis.
  • A heart rate recorded at 140 beats per minute would be unusual in a case of viral gastroenteritis, most particularly at the onset of the illness.
  • Severe pain is not normally a sign of viral gastroenteritis. The pain medication provided by the ambulance crew and in the Emergency Department suggest that Mrs Inches was suffering a significant level of pain.
  • The ambulance records indicate that Mrs Inches' abdominal pain commenced shortly after eating her evening meal. This is unusual in a case of viral gastroenteritis where pain is usually preceded by a feeling of unwellness, nausea and then a need to use the toilet.
  • The low white blood cell count of 3.1 is a strong indicator of sepsis and not viral gastroenteritis. The reference to a left shift and vascuolation is a further indicator of sepsis.
  • The elevated bilirubin was also suggestive of sepsis and not viral gastroenteritis.
  • A proper nine quadrant examination by palpation of the abdomen would almost certainly have detected tenderness, a sign indicative of sepsis.

It is apparent that Dr Dudgeon's decision to rule out sepsis as the diagnosis was governed by two principal factors. First was his interpretation of the blood results, specifically his belief that sepsis was ordinarily associated with a high C-Reactive Protein level (it was within normal limits) and a white cell count outside the normal range (it was outside but below the normal range). In his re-consideration of the matter Dr Dudgeon has since acknowledged that Mrs Inches' white cell count "was mildly low" and this "may have been significant." I have already noted that Dr Bell considers the low white cell count to be a strong indicator of sepsis. In fact it is his further advice that this result by itself showed that Mrs Inches was not suffering from viral gastroenteritis, that she was seriously unwell and that she required immediate referral to a consultant surgeon.

The second factor relevant to Dr Dudgeon's assessment that Mrs Inches was not suffering from sepsis was the apparent marked improvement in her condition. He described her as pain-free, smiling and able to walk upright, all signs which in his opinion constituted a presentation inconsistent with sepsis. However, Dr Bell advises me that in circumstances where sepsis is a possible diagnosis, it is unwise to overly rely on the patient's apparent improvement after symptom treatment as a basis for dismissing the diagnosis. He points out that approximately 40% of in-hospital patients transferred to an Intensive Care Unit have a septic episode that resolves but recurs later with a vengeance.

I acknowledge that Dr Bell's opinions in this matter have been formulated with the benefit of hindsight. Nevertheless, I accept his view that when Mrs Inches presented at the Private she was suffering from sepsis and this diagnosis should have been made. In the very least the diagnosis should not have been dismissed and she most definitely should not have been discharged home. Instead, again accepting the opinion of Dr Bell, I am satisfied that Mrs Inches' condition was sufficiently serious to require her immediate referral to a consultant surgeon.

The failure on Dr Dudgeon's part to diagnose Mrs Inches' sepsis led to her being discharged home without any intervening investigation and treatment. Initial investigation would have involved a CT scan of the abdomen which almost certainly would have identified a perforated bowel and the urgent need for surgery. I am advised by Dr Bell that had these steps been promptly taken Mrs Inches had an approximate 75% chance of surviving her sepsis. Regrettably this did not happen and she was denied all prospects of survival.

Comments and Recommendations:

In my recent findings made following an investigation of the death of Mr Barry Lindsay Tetley I made this statement which warrants repeating in this case:

"This is another in a series of recent coronial cases investigated by me where a person has died because of a failure to make a timely diagnosis of sepsis. This leads me to again remind the medical fraternity that sepsis is a life-threatening condition which is often difficult to diagnose because it can present in multiple circumstances and because of a tendency for its signs to fluctuate. Its diagnosis requires close vigilance of the patient's vital signs and an understanding that particular changes or fluctuations in those signs may be explained by sepsis."

I have decided not to hold a public inquest into this death because my investigations have sufficiently disclosed the identity of the deceased, the date, place, cause of death, relevant circumstances concerning how her death occurred and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest would elicit any significant information further to that disclosed by the investigations conducted by me. The circumstances of the death do not require me to make any further comment or any further recommendations.

I conclude this matter by conveying my sincere condolences to Mrs Inches' family.

Dated the 18 of November 2014 at Hobart in the State of Tasmania.

Rod Chandler