Sepsis Death: UTI Missed Due to Language Barrier

A woman died from sepsis following childbirth in western Sydney, with a coroner's court determining that a missed diagnosis of a urinary tract infection (UTI) contributed to her death. The 32-year-old immigrant, who arrived in Australia around 2010, passed away at Liverpool hospital on February 4, 2019, three days after giving birth.

The inquest revealed multiple missed opportunities to diagnose the UTI, including at a January 21, 2019, hospital appointment and again upon admission for labor on January 31. A significant factor identified was the failure to consistently provide interpreter services, particularly during critical interactions where the patient expressed severe pain.

Despite complaints of pain and difficulty urinating, her condition deteriorated. On February 4, a home visit by a midwife noted distress, but the midwife advised seeing a GP instead of calling an ambulance. By the time she was taken to Liverpool hospital, her condition was critical, and she later went into cardiac arrest.

Subsequent postmortem examination confirmed sepsis as the cause of death, stemming from a kidney infection consistent with an undiagnosed UTI. Since her death, the South Western Sydney Local Health District has strengthened practices regarding interpreter use and introduced new policies for detecting abnormal symptoms and improving escalation pathways.