Coronial
NSWother

Inquest into the death of Madeleine Duffy

Deceased

Madeline Rose Duffy

Demographics

18y, female

Date of death

2014-04-06

Finding date

2015-11-27

Cause of death

asphyxiation and respiratory failure on a background of severe dystonic quadriplegia

AI-generated summary

Madeline Duffy, 18 years old with severe dystonic quadriplegic cerebral palsy, died from asphyxiation and respiratory failure while in respite care. She was positioned on her side in bed with pillows, contrary to her usual back-lying sleeping position, and was not checked for at least 1.5 hours after 6-6:30am despite normally waking around 7-7:30am. When found at 8:15am, her face was pressed against a pillow wedged against the bed rail. The coroner found the critical clinical lesson was the failure to conduct regular morning checks, which might have detected her distress or compromised state and enabled life-saving intervention. Additionally, documentation gaps existed regarding her gastronomy feeding regime (receiving 2 feeds instead of prescribed 4). The case highlights the critical importance of regular monitoring of non-communicative, immobile patients with severe movement disorders who cannot self-rescue from dangerous positions, and maintaining accurate, up-to-date care documentation in residential settings.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

rehabilitation medicineneurologypathology

Error types

communicationdelaysystem

Drugs involved

baclofendiazepamdiazepamomeprazoleparacetamol

Clinical conditions

severe dystonic quadriplegic cerebral palsyGMFCS level 5dysphagiagastro-oesophageal refluxasthma

Procedures

gastrostomy tube feeding

Contributing factors

  • change in sleeping position from usual back-lying to side-lying on day of death
  • failure to conduct regular checks during morning period of 6:30am to 8:15am
  • positioning of pillow against bed rail that patient's face became pressed against
  • patient's inability to self-rescue due to severe movement disorder and involuntary dystonic posturing
  • staff not checking on patient after normal wake time of 7-7:30am
  • inadequate handover communication regarding new sleeping position

Coroner's recommendations

  1. Files should be updated regularly to reflect changes in care regimes for clients as and when they occur
  2. Proper records must be kept as to when clients are medicated and what medication they receive
  3. Formalised handover policy should be implemented and staff trained, particularly for shift changes involving morning care
  4. The handover checklist for awake night shift to morning shift should be completed and documented with both staff initialling
  5. Medication charts should only be completed contemporaneously
  6. Regular checks should be maintained during morning periods, particularly for clients with known propensity to assume dangerous postures
Full text
Official source Archived copy

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Source and disclaimer

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