A fatal ascending spinal subdural empyema due to Streptococcus intermedius in a socially vulnerable patient: Forensic perspectives on diagnostic delay and implicit bias.

A fatal case of ascending spinal and cranial subdural empyema (SDE) caused by Streptococcus intermedius in a socially vulnerable 63-year-old man with repeated emergency department (ED) admissions is reported. Despite persistent lower back pain and neurological symptoms, advanced neuroimaging and additional clinical and laboratory evaluation were delayed, ultimately leading to septic shock and multi-organ failure. Forensic and postmortem investigations identified the pathogen and clarified the cause of death. The case highlights the forensic relevance of missed clinical red flags and the potential interplay between implicit bias - defined as unconscious attitudes and beliefs that may drive intentional discriminatory actions - organizational factors, and diagnostic delays in a life-threatening condition affecting an underserved patient. Increased awareness of vulnerability-associated diagnostic bias, together with systematic organizational interventions, is needed to promote equity in emergency care and reduce healthcare disparities among marginalized populations.