Coronial
QLDhospital

Thoresen, Cynthia

Deceased

Cynthia Thoresen

Demographics

88y, female

Coroner

Clements

Date of death

2009-01-03

Finding date

2013-05-22

Cause of death

pulmonary thromboembolism due to fractured right femur due to a fall

AI-generated summary

Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical attention despite clear evidence of severe pain and immobility. The patient remained bedbound in filthy conditions, developing pressure sores and malnutrition. Hospital staff provided appropriate, multidisciplinary care including prophylactic anticoagulation, but the patient deteriorated and died from pulmonary embolism. Clinical lessons: family carers require oversight through mandatory annual medical reviews; elderly patients with dementia need access to general practitioners; fracture complications demand urgent medical evaluation; and signs of elder neglect must trigger welfare intervention immediately.

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

Specialties

orthopaedic surgeryemergency medicinegeriatric medicinepalliative carerespiratory medicinegeneral medicine

Error types

delaysystem

Drugs involved

morphineenoxaparinibuprofenparacetamol/codeinemidazolamhaloperidol

Clinical conditions

femoral shaft fracturepulmonary embolismosteoporosisAlzheimer disease/dementiadeep venous thrombosis riskpressure ulcers/pressure soresmalnutritiondehydrationurinary tract infectionpleural effusioncoronary atherosclerosis

Procedures

tractionattempted fracture reduction under general anaesthesiachest aspirationnasogastric tube insertion

Contributing factors

  • three-week delay in seeking medical attention after fall
  • prolonged immobility
  • fracture healing without surgical fixation
  • severe malnutrition and dehydration
  • pressure sores and skin contamination
  • advanced age and dementia
  • osteoporosis
  • lack of general practitioner oversight for 5+ years
  • inadequate family carer management
  • fluid overload from intravenous therapy

Coroner's recommendations

  1. A recipient of the carer's benefit should be required to submit an annual independent medical review of the person being cared for to prevent appalling decline in wellbeing of vulnerable elderly persons
  2. The matter should be referred to the Attorney General for consideration of referring the issue of review of legislation to the Queensland Law Reform Commission to create a new offence more akin to offences relating to cruelty to children, to address gaps in existing law for prosecuting elder neglect
Full text

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