Finding of Inquest into the Death of Rita Ann Broadway

Background

On 11 November 2013 Ms Broadway was admitted to Royal Adelaide Hospital for bilateral lower leg cellulitis. During that admission her treatment included the placement of a long-term indwelling catheter for urinary incontinence. Following her discharge from the Royal Adelaide Hospital the Royal District Nursing Service (RDNS) assisted her with the management of her indwelling catheter.

On 13 December 2014, Ms Broadway attended Modbury Hospital by way of ambulance. Ms Broadway told the officers that for a week she had suffered from a minor trauma to her vaginal area caused by a wheelchair.

Upon arrival at Modbury Hospital, a member of the nursing staff recorded a history of two weeks of increased urine output and smell and the nurse's assessment was of a possible urinary tract infection.

Ms Broadway was examined on two occasions by Dr Quigley, resident medical officer in the Modbury Hospital Emergency Department, and once by Dr Davidson, consultant in charge of the Emergency Department that night.

From Dr Quigley's discharge summary, it appears that Dr Quigley's conclusion was that Ms Broadway had a local irritation from the wheelchair, she had pain from the indwelling catheter, elements of dermatitis medicamentosa applied to the area and Lichen sclerosus/planus.

It was expert witness, Professor Kelly's opinion that urinary tract infection should have been the most important diagnosis in the discharge summary, or sepsis of a catheter associated urinary tract infection.

Findings

It was Professor Kelly's opinion that Ms Broadway should have received antibiotics for a suspected urinary tract infection and her catheter should have been changed. It was Professor Kelly's opinion that the decision not to change the catheter when requested by Ms Broadway was unjustified.

The Coroner accepted Professor Kelly's opinion that this management of Ms Broadway fell below what would be accepted by peers as reasonable practice.

Further, the Coroner found that had Ms Broadway's catheter been changed on the night of 13 December 2014 and had she been placed on antibiotic cover, her chances of survival would have been in the order of above 80% or 90%.

The Coroner recommended that the Minister for Health investigate the development of a protocol for diagnostic criteria for catheter associated urinary tract infection in adults within the South Australian health system.

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