Coronial
NSWaged care

Inquest into the death of Vakabauta LEONE

Deceased

Vakabauta Leone

Demographics

47y, female

Coroner

Decision ofDeputy State Coroner Ryan

Date of death

2019-03-15

Finding date

2021-09-22

Cause of death

complications of rapidly progressing motor neurone disease

AI-generated summary

A 47-year-old woman with motor neurone disease died from respiratory complications while in immigration detention, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt CPR, apparently believing an undocumented 'not for resuscitation' directive existed. No such directive was found. Ambulance paramedics commenced CPR after significant delay. She was intubated but life support was withdrawn following neurological assessment and family discussion. The coroner found nursing staff acted in good faith given the terminal nature of her condition, but identified lack of clarity about her resuscitation status as problematic. The delay in CPR may have affected her survival prospects, though causation cannot be established. The aged care facility has since implemented policies to clarify resuscitation decision-making processes.

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

Specialties

palliative careemergency medicineneurology

Error types

communicationdelay

Clinical conditions

motor neurone diseaseCushing's syndromehypertensiondiabetes mellitusrespiratory distressaspiration pneumonia

Procedures

feeding tube insertionoral suctioningcardiopulmonary resuscitationintubationmechanical ventilation

Contributing factors

  • absence of documented 'not for resuscitation' directive despite unclear verbal understanding among staff
  • lack of clarity about resuscitation status among nursing staff
  • delay in CPR initiation prior to ambulance arrival
  • rapid progression of motor neurone disease with respiratory compromise

Coroner's recommendations

  1. The aged care facility has undertaken to develop clear policies regarding circumstances in which CPR would be administered to residents, train staff in these policies and in developing care plans and resuscitation directives, and improve engagement with residents and families about resuscitation preferences. The coroner found this work obviates the need for formal recommendations.
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