She suffered inhalation burns from a fire in her house. Her esophagus and trachea were severely burned. She needed a feeding tube to eat.
The feeding tube was originally put in correctly and worked for a few days before needing to be cleaned.
The tube was removed, cleaned and reinserted.
The problem was that the feeding tube was not put back into the correct place.
Within the next three days the patient's medical condition deteriorated. No doctor could figure out why she was getting worse.
She died and her doctors couldn't explain why she died...until an autopsy was done.
The autopsy confirmed that the feeding tube was not put into the correct position. Instead, all the protein was flowing into the peritoneal cavity- someplace it never should have been. It became infected and spread throughout her entire body. This is known as sepsis.
Her death was caused by unrecognized and untreated sepsis.