Deceased
Viola Diana Clarke
Demographics
86y, female
Coroner
Coroner Lawton
Date of death
2016-02-20
Finding date
2020-06-02
Cause of death
aspiration pneumonia
AI-generated summary
Viola Diana Clarke, an 86-year-old woman with multiple comorbidities including congestive heart failure, COPD, renal failure, gastric reflux and dysphagia, died from aspiration pneumonia. She was administered incorrect medication at her aged care facility on 9 February 2016, which was immediately detected and managed. She deteriorated and was admitted to hospital on 10 February 2016, where she subsequently died. The coroner could not establish with comfortable satisfaction when the aspiration occurred or whether the medication error contributed to it. The coroner found no matter of public safety arose. Key clinical lessons include recognition that aspiration risk is multifactorial in elderly patients with dysphagia and reflux, and the importance of immediate detection and protocol-driven response to medication errors, which occurred appropriately in this case.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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