Inquest into the death of Sylvia CONFOS
Deceased
Sylvia Confos
Demographics
87y, female
Date of death
2016-08-26
Finding date
2019-09-27
Cause of death
Natural causes in the context of multiple co-morbidities including a sacral ulcer
AI-generated summary
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in March 2016 or ulcerated by August, despite this being identified by wound consultants as requiring family discussion about active vs. passive treatment; (2) Gaps in wound monitoring—no monthly photos in June 2016, delaying recognition of progression from stage 2 to ulcer; (3) Mattress settings error—dynamic mattress set incorrectly (5.5 for 145kg patient vs. 40kg actual weight), contributing to pressure injury; (4) Clinical coordination breakdown—multiple staff (nurses, Clinical Care Co-ordinator, GP, wound consultant) assumed someone else would notify family, with no one taking responsibility; (5) Inadequate vital signs monitoring for infection risk. Clinicians should document and escalate communication responsibilities, ensure families are informed of significant deteriorations, and verify equipment settings against actual patient parameters.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to communicate wound ulceration to family despite wound consultant recommendation
- Delayed recognition of wound progression from stage 2 to ulcer due to gap in photographic documentation in June 2016
- Incorrect dynamic mattress setting (5.5 for 145kg patient when patient weighed 40kg)
- Patient left to sit in tub chair on wound despite consultant recommendation against seating
- Absence of vital signs monitoring (temperature/pulse) despite infection risk
- Breakdown in clinical team communication with no single person accepting responsibility for family notification
- Absence of documented discussion with family regarding active vs. passive treatment approach
- Inadequate handover when Clinical Care Co-ordinator went on paternity leave
- No follow-up with wound consultant when wound progressed from stage 2 to stage 3, despite consultant recommendation to review in 4 weeks if no improvement
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