Deceased
Peter Greenhill
Demographics
57y, male
Coroner
Coroner M. Kay Robertson
Date of death
2009-10-11
Finding date
2010-12-08
Cause of death
Sepsis and acute renal failure due to pneumonia
AI-generated summary
A 57-year-old man with spina bifida, intellectual disability, and multiple comorbidities presented to hospital with chest pain, breathing difficulty, atrial fibrillation, and hypoxia. He was diagnosed with chest sepsis, septic shock, respiratory failure, and acute renal failure. Despite ICU admission and treatment with antibiotics, inotropes, and supportive care, his condition deteriorated and he died within 3 days. The finding does not identify preventable errors or lapses in care. Clinical lessons relate to early recognition and aggressive management of sepsis in vulnerable patients with complex medical and social needs, ensuring timely escalation of care for respiratory compromise and shock.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
FORM 37 Rule 60(1)
Section 67 of the Coroners Act 2008
Court Reference: 4850/09 Inquest into the Death of Peter Greenhill
Delivered On: 8th December 2010 Delivered At: Ballarat Hearing Dates: 8th December 2010 Findings of: M. Kay Robertson
Place of death: Ballarat Base Hospital
FORM 37 Rule 60(1)
Section 67 of the Coroners Act 2008 Court Reference: 4850/09 In the Coroners Court of Victoria at Ballarat
IM, Kay Robertson, Coroner having investigated the death oft
Details of deceased:
Surname: Greenhill First name: Peter Address: 68 Churchill Ave Ararat Vic 3377
AND having held an inquest in relation to this death on 8th December 2010
at Ballarat Law Courts find that the identity of the deceased was Peter Greenhill and death occurred on 11 October 2009 at Ballarat Base Hospital from 1a Sepsis and acute renal failure ib Pneumonia 2 Severe intellectual disability and spina bifida in the following circumstances:
Mr Peter Greenhill was 57 years of age, Since 1995 he had lived at 68 Churchill Street Ararat, a Department of Human Services Community Residential Unit.
Mr Greenhill had an history of spina bifida ,thoracic scoliosis, urinary incontinence, right nephrostomy, retinal detachment, leg ulceration, right inguinal hernia repair, asthma and intellectual disability.
On the 8" of October, 2009 Mr Greenhill arrived back at the Residential Unit from his day placement in obvious pain and having trouble breathing. At 4:30pm, Mr Greenhill was taken to Ararat Medical Centre from where he was admitted to Ararat Hospital suffering atrial fibrillation and hypoxia. His condition deteriorated and Mr Greenhill was transported to Ballarat Health Services Intensive Care Unit on 10" October, 2009,
Further tests led to a diagnosis of chest sepsis and septic shock, tespiratory failure, rapid atrial fibrillation, acute renal failure and electrolyte imbalance. Mr Greenhill was sedated and treated with antibiotics, anti- thrombotic, anti-arrythmic medication and inotropes. Mr Greenhill’s condition continued to deteriorate and he passed away during the afternoon of 11" of October, 2009.
Dr, Anthony Roberts reviewed the medical records and conducted an external examination, He concluded the cause of death was sepsis and acute renal failure and pneumonia.
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