| 20.09,19. 05:24 PM |
Doctors failed to act on sepsis risk in the hours before Joanne Craig's death, coroner finds
Photo: If doctors at the Katherine hospital had acted quicker, Joanne Craig's life could have been saved. (ABC News: Iskhandar Razak)
Despite previous inquests into the failure to identify and treat sepsis in Northern Territory hospitals, Joanne Craig was left to deteriorate without the antibiotics that could have saved her life.
Ms Craig died of organ failure caused by sepsis, 12 hours after presenting to the Katherine Hospital in January 2018.
In handing down his findings today, NT coroner Greg Cavanagh detailed how the medical professionals treating Ms Craig failed to recognise her condition and intervene in time.
It is not the first time the NT coroner has criticised Territory health services' handling of sepsis.
A damning coronial inquest in 2018 found that an elderly man was "left to die untreated in pain" and another inquest in March this year showed Royal Darwin Hospital staff had not properly informed a family of the risks of sepsis.
Antibiotics withheld for over 10 hours
The attending doctors knew early on that Ms Craig's condition was either viral or bacterial, but did not commence antibiotic treatment.
The only way to treat sepsis is the early administration of broad-spectrum intravenous antibiotics.
According to one expert consulted in the inquest, Ms Craig should have been provided this treatment by midday at the latest, after arriving at the hospital at 9:12am.
Instead antibiotics were not administered until 7:20pm, 10 hours after her initial presentation and two hours before her death.
Mr Cavanagh said withholding the antibiotics "gave her no chance for survival".
During the inquest, expert witness associate professor Dr John Raftos said doctors should have acted sooner.
"The only safe and reasonable medical synthesis of this presentation, regardless of any clinical guideline, would be that Ms Craig had a serious bacterial infection," he said.
"When you're taking a bet on a patient's life ... the aim for treatment of sepsis is you give antibiotics, and if it turns out to be a viral infection, nothing was lost.
"But if you don't give the antibiotics, you can't go back and give them at the appropriate time.
"You don't wait until someone's dying before you treat them."
Indigenous people more vulnerable
Ms Craig, who was a Wurrumunga woman, was also more vulnerable to the infection.
Aboriginal and Torres Strait Islander people lack immunity to the streptococcus pneumoniae bacteria that can cause septicaemia but it is vaccine preventable.
The Australian Immunisation Handbook recommends that all Indigenous adults receive the vaccination at the age of 50, with a further dose five years later.
Statistics from the NT Centre for Disease Control show that on average 50 per cent of people in the Northern Territory aged between 50 and 60 have been vaccinated.
Katherine had the lowest level of coverage in the Territory, with only 38 per cent of people vaccinated.
Mr Cavanagh also found that there was poor documentation for a patient who was in potential danger from sepsis.
"There was, for instance, no fluid balance chart utilised at any time," he said.
"Such a chart may also have assisted the doctors to understand that they were unlikely to have been dealing with hypovolemic shock after 3:30pm."
Mr Cavanagh's recommendations included more efforts to provide Indigenous people with the vaccine and to improve the competency of staff at the Top End Health Service in identifying and treating sepsis.