Inquest into the death of Carney Schultz
Deceased
Carney Schultz
Demographics
28y, female
Date of death
2015-04-21
Finding date
2018-02-16
Cause of death
complications of epilepsy
AI-generated summary
Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seizure around 3:20am managed by a disability support worker (DSW) without medical intervention. Hours later, a second unwitnessed seizure likely caused her death. Critical clinical lessons: (1) DSWs lacked training on seizure duration timing, leading to underestimation of seizure severity; (2) The DSW who managed the first seizure failed to call an ambulance despite protocol requirements, influenced by perceived criticism from previous incidents; (3) Staff rostering gaps meant untrained DSWs worked night shifts alone when seizure supervision was critical; (4) Epilepsy Management Plans were overly complex with inconsistent documentation across multiple records; (5) Lack of multidisciplinary team approach and no mandatory training in seizure protocols for casual staff. The coroner found the likely cause was complications of epilepsy (possibly SUDEP—Sudden Unexpected Death in Epilepsy), though precise mechanism couldn't be determined. Systemic improvements have since been implemented including mandatory midazolam training and better documentation practices.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Seizure management protocol not followed—ambulance not called after first seizure despite suspected 8-minute duration meeting protocol threshold
- Lack of training for disability support workers on accurate measurement of seizure duration
- Lack of mandatory training in midazolam administration for casual and night-shift staff
- DSW influenced by perceived criticism from family and peers regarding previous ambulance call, choosing not to escalate despite protocol
- Solo night shift staffing with untrained personnel during high-risk period for seizures
- Overly complex and inconsistent Epilepsy Management Plan with redundant documentation across multiple records
- Lack of multidisciplinary team approach to epilepsy management planning
- Inadequate induction and verification processes for new disability support workers
- Possible unwitnessed second seizure between 8:20am and 8:50am resulting in death while lying face-down in pillow
Coroner's recommendations
- Provide findings to the Chief Executive Officer of the National Disability Insurance Agency for consideration of identified shortcomings in supported living services provided to Carney Schultz and lessons learned
- Adopt a multidisciplinary team approach to drafting and implementation of appropriate Epilepsy Management Plans by supported living (group accommodation) disability service providers in the Illawarra Shoalhaven region
- Provide findings to the Managing Director of the House With No Steps (now operating the Figtree home) for consideration of identified shortcomings and adoption of multidisciplinary approach to Epilepsy Management Plans
Full text
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