Ms C - Non-inquest findings

Contributing factors

• Large necrotic sacral pressure ulcer with deep tissue and bone involvement
• Severe dehydration (hypernatraemia)
• Poor nutritional status with low protein levels
• Dementia limiting patient cooperation and oral intake
• Immobility from dementia and wheelchair-dependence
• Advanced age (90 years)
• Significant cardiac disease (coronary atherosclerosis, mitral stenosis, congestive cardiac failure)
• Recent pulmonary embolus
• Osteoporosis with falls
• Lack of multidisciplinary assessment (speech pathology, dietetics)
• Inadequate communication with Enduring Power of Attorney
• Failure to debride ulcer when indicated

Coroner's recommendations

1. Aged care facilities should implement clear protocols for identifying and consulting Enduring Power of Attorney holders in all care decisions, particularly for residents with dementia
2. Consistent documentation and maintenance of wound care charts and care plans for all pressure areas is essential
3. Multidisciplinary assessment including speech pathology and dietetics should be obtained for residents with difficulty swallowing or refusing oral intake
4. Appropriate pressure-relieving equipment (cushions, mattresses) must be provided and maintained for all at-risk residents
5. Timely escalation and referral for wound debridement when conservative measures are insufficient should be clearly documented