Inquest into the Death of Colin Stanley Francis NICHOLSON
Inquest into the Death of Stanley Francis NICHOLSON
Delivered on : 17 April 2025
Delivered at : Perth
Finding of : Deputy State Coroner Linton
Recommendations : Yes
I recommend that the Department of Health allocate appropriate resources to fund the procurement and deployment of digital microscopy solutions (such as CellaVision) throughout the state in order to improve the timeliness and accuracy of Haematologist review for patients living in regional areas.
Orders/Rules : N/A
Suppression Order : Yes
There be no reporting or publication of the name of the Laboratory Scientist [name redacted].
Summary : Colin Stanley Francis Nicholson was a 69-year-old man who died at Bunbury Regional Hospital on 18 November 2021. Colins death was not initially reported to the State Coroner, and instead a medical certificate cause of death was issued recording Colin died from septic shock with multiorgan dysfunction on a background of neutropenia and other health conditions.
As a result of later internal reviews, Colin’s death was reported by the WA Country Health Service as there were possible concerns about the medical care provided to Colin in the weeks leading up to his death. The concerns were not related to his care at Bunbury Regional Hospital, but instead the care Colin had received from general practitioners and at the hospital in Collie.
The Deputy State Coroner held a discretionary inquest in Bunbury Courthouse on 30 September 2024 to 3 October 2024, to explore the circumstances of Colin’s death. The primary focus of the inquest was the management of Colin’s identified neutropenia (in essence low infection fighting white blood cells) and the delay in a bone biopsy that would have identified his Acute Myeloid Leukemia (AML), as well as the initial failure to identify that Colin had developed sepsis and required urgent antibiotics and supportive treatment.
The evidence suggested that Colin’s death may have been preventable with medical treatment, or at least that if he had been diagnosed earlier and treatment commenced, he may have survived for a prolonged period before his illness led to his death. With the benefit of hindsight, all of Colin’s blood results in the last few months prior to his death showed he was developing AML, and this placed him at high risk of infection leading to sepsis. If Colin had been diagnosed with AML at an earlier stage, there remained the option of commencing treatment.
The Deputy State Coroner found that the cause of death was septic shock with multi-organ failure in a man with neutropenic sepsis on a background of recent acute myeloid leukemia diagnosis, and that the death occurred by way of natural causes.
Catch Words : Discretionary Inquest : South West : Natural Causes : Leukemia
Last updated: 23 May 2025