Doctors at Katherine Hospital have been criticised for not acting fast enough to treat a bacterial infection which killed a respected Territory pastoralist last year.
A Coroner in Darwin today completed an inquest into the death of Joanne Craig, 57 who died on January 24 last year, a day after attending the hospital feeling unwell.
Ms Craig was the mother of four children and the well regarded manager, with her partner Steven, of Mistake Creek Station, located about 630km southwest of Katherine.
She was having dinner at the Katherine Golf Country Club on January 23 last year when she complained of feeling cold and feverish.
The following morning she was still unwell and Mr Craig drove her to the Emergency Department of the Katherine Hospital, the inquest was told.
"The working diagnosis was a likely viral illness with no clear source of infection. The plan was for further observations and investigations," the inquest heard.
"Her condition deteriorated throughout the day. She went into cardiac arrest at 8.42pm. She was declared life extinct at 9.25pm."
According to Forensic Pathologist, Dr Marianne Tiemensma, she died due to multiple organ failure caused by sepsis that was due to streptococcus pneumoniae infection.
The death of Mrs Craig was likely to have been preventable, Coroner Greg Cavanagh said.
Coroner Cavanagh recommended a series of changes to the way Top End Health treats its patients.
In particular, the Coroner recommended GPs "make every effort" to provide to Aboriginal and Torres Strait Islander people the Pneumovax23 (23vPPV) vaccination in accordance with the Australian Immunisation Handbook.
"I recommend that the Top End Health Service do all things necessary to ensure its staff are competent in the recognition of sepsis and escalation of treatment and that such efforts are ongoing."
The inquest was told the Katherine Hospital now has a video to instruct staff on recognition and treatment of sepsis.
"For a patient who from the outset was recognised to be in potential danger from sepsis the documentation is very poor," Mr Cavanagh said.
"There was for instance no fluid balance chart utilised at any time. Given that urine output is a significant parameter when identifying sepsis that seems less than adequate. 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.
"One of the significant concerns of the family was that very early on in the care of Mrs Craig the doctors understood that the infection was either viral or bacterial. If viral, there was likely no real danger. If bacterial, there was real danger (sepsis).
"However, the consequences of withholding antibiotics was not discussed with Mrs Craig or her family. The family are confident that if that discussion were had she would have sought antibiotic treatment.
"In circumstances where withholding treatment may well have had and did have fatal consequences, that failure to discuss the options for treatment was significant."
Coroner Cavanagh said it was apparent when she arrived at Katherine Hospital and was triaged at 9.12am she was suffering from sepsis.
"The only way to treat sepsis is the administration of broad spectrum intravenous antibiotics at an early stage.
"According to one expert she should have been provided broad spectrum antibiotics by midday at the latest. If that had happened she is likely to have survived. According to another expert she should have had antibiotics shortly after 3.30pm. If that had happened she may well have survived.
"However withholding antibiotics until 7.20pm gave her no chance for survival."
The inquest was also told the failure to identify the deterioration was the subject of reviews by Katherine Hospital, Top End Health Service and the Department of Health.
"At Katherine Hospital improvements were sought to be made regarding transfer and clinical handover of patients between the emergency department and the ward, and upskilling in the identification of deteriorating patients and the appropriate escalation of care.
Staff at the Katherine Hospital have made a video for continuing education on the dangers of sepsis along with its identification and treatment. There has also been personal learning from the doctors involved in Mrs Craig's care."