Orton, David - Non-inquest findings

Contributing factors

• Undiagnosed toxic megacolon
• Chronic constipation inadequately managed
• Salmonella infection (possibly chronic carrier status)
• Microaspiration pneumonia
• Malnutrition and weight loss
• Lack of specialist gastroenterology involvement
• Pain misattributed to behavioural issues in non-verbal patient
• Absence of case manager for 16 months
• Inadequate coordination between disability services and hospital
• No palliative care involvement despite progressive deterioration
• Severe kyphoscoliosis limiting mobility
• Floor-crawling causing skin abrasions leading to cellulitis and Staphylococcus aureus infection

Coroner's recommendations

1. Support staff and carers should be trained to recognise signs of serious illness and equipped to perform basic observations (temperature, pulse, heart rate)
2. All deaths in care of people with disability must be reported to the Coroner to improve understanding of prevalence and circumstances
3. People with disability in residential care should have a designated person responsible for coordinating and reviewing their health care
4. Annual comprehensive health reviews must be prioritised for people with disability in residential care, including regular medical check-ups and dental care
5. Disability residential services should have a designated role responsible for ensuring health care strategies are implemented, appointments booked and attended, hand-held records maintained, and behavioural support coordinated
6. Support staff and carers should be aware of signs, symptoms, and risks associated with chronic constipation and actively seek medical advice
7. Appropriate tools must be used to monitor daily bowel motions in people with chronic constipation
8. Health practitioners should be alert to chronic constipation in patients with intellectual and cognitive disabilities, recognising behavioural changes, sleeping pattern changes, refusal to eat, weight loss, nausea, and vomiting as possible indicators
9. Constipation in people with disability should be appropriately managed by specialists (gastroenterologists), not trivialised
10. People with disability with multiple and complex needs should be prioritised during triaging in health care settings due to overrepresentation of gastrointestinal issues
11. Greater standardisation in practice is required for management of personal care needs and eligibility requirements for entry into disability facilities, with prompt transition to higher care facilities if required
12. Processes for care transitions should be developed and reviewed with input from appropriately qualified medical personnel
13. Pain in non-verbal patients must not be dismissed as behavioural; alternative physical explanations must be actively investigated
14. Early engagement with palliative care services should be considered for people with progressive functional decline, regardless of primary diagnosis
15. Clear care pathways and protocols should be established for specialist referrals in disability populations, with hospitals recognising severity of condition in such referrals
16. Persons with cognitive impairment or intellectual disability require additional support to follow up on outpatient specialist appointments and attend appointments
17. Dietician involvement should be maintained throughout care management for patients with malnutrition
18. Improved coordination and shared care arrangements between disability services and hospital care providers
19. Case managers should be assigned early in the course of chronic or complex health issues in people with disability to ensure consistency of care
20. A standard diagnostic protocol should be developed for non-verbal disabled people to ensure thorough investigation of unexplained symptoms