Pneumonia Patient's Blood Pressure Plummets Before Cardiac Arrest, Leaving Her With Multiple Amputations
A 45-year-old woman sent home from urgent care with pneumonia later went into septic shock, suffered a cardiac arrest and required multiple amputations after her blood pressure collapsed and treatment lagged overnight, an Expert Witness Newsletter case review published on 28 September 2026 says.
The events date from 2013 and were settled at mediation in December 2017. They have returned to clinical discussion because they turned on missed vital signs, delayed antibiotics and an unclear handover while she boarded in an emergency department.
Key facts: She had gastric bypass surgery and presented with fever, chills, dizziness and shortness of breath. The temperature was 100.8F and pulse 134. She received azithromycin and left before the formal chest film report was filed. Hours later she was in hospital with a lactate of 4.8 and worsening pneumonia.
Missed Blood Pressure and an Early Discharge
The urgent-care note recorded fever and tachycardia but no blood pressure. Left-sided pneumonia was diagnosed and she left on a macrolide. The radiology report arrived after she had gone.
She worsened through the day and reached a nearby emergency department at 11pm. Observations then drifted down. Blood work showed a lactate of 4.8 and 24 per cent bands. The first fluid bolus was 500ml of saline. Piperacillin-tazobactam was given at 1.40am and vancomycin at 2am, about two hours 40 minutes and three hours, respectively, after she arrived.
No intensive-care bed was free, so she boarded overnight. By morning her pulse was in the 150s to 160s, systolic pressure was 88mmHg and oxygen saturation was 88 per cent.
Hours of Boarding Before Cardiac Arrest
A nurse note at 7.30am recorded that the intensive-care consultant, told of those figures, said he was not coming in and that the hospitalist would admit her. The hospitalist arrived soon after. At 10.30am she reached intensive care and was intubated. She then arrested, was resuscitated and spent a long period on several vasopressors. She survived with multiple amputations.
A lawsuit named the urgent-care doctor, the radiologist, the emergency physician, the hospitalist, the intensive-care doctor and the hospital. Experts criticised the missing blood pressure, delayed fluids and antibiotics, and split responsibility during boarding.
Mediation produced a settlement. The reviewer said court records appeared to suggest the hospital agreed to pay about £2.65 million (3.5 million) to be dropped from the lawsuit, although the figure was presented as an inference rather than a confirmed settlement term. The claimant's firm received a little more than £756,000 ($1 million) of the settlement.
Current NICE guidance says adults at high risk of severe illness or death from sepsis should receive broad-spectrum intravenous antibiotics within one hour of calculating their NEWS2 score on initial emergency-department assessment or ward deterioration. It also recommends an intravenous fluid bolus without delay, within one hour of identifying high risk, unless contraindicated.
What Clinicians Took From the File
Physician assistant Brian Renfrow, commenting on the review, said that in his experience the delays would not have been considered remotely acceptable even in poorly equipped critical-access facilities.
The reviewer said the case appeared to involve confusion over whether the ED doctor or hospitalist was responsible for her care while she remained in the ED. He also said each team assumed the other was in charge after the night shift ended.
The write-up leaves the woman unnamed and severely disabled after delayed pneumonia treatment that ended in shock, arrest and amputation.