Non-inquest findings into the death of Diane Margaret Crowther

Contributing factors

• overlooked old dressing retained in abdominal skin fold for unknown period
• delayed creation of wound care plan (7 days post-discovery)
• reactive rather than proactive wound surveillance
• failure to escalate deteriorating wound to hospital at critical point (23 August 2023)
• inadequate analgesia during wound care procedures
• poor communication with family regarding goals of care and palliative pathway
• lack of clarity about advance care planning and decision-making
• inadequate wound swab follow-up
• insufficient clinical assessment skills to identify when to escalate
• lack of clinical oversight and wound management knowledge
• poor continuity of care

Coroner's recommendations

1. Implementation of proactive wound surveillance and monitoring for high-risk patients, particularly those with obesity and skin fold complications
2. Daily review of wounds with systematic separation of skin folds, cleaning with appropriate agents, airing where possible, and use of barrier creams and dressings
3. Immediate creation of wound care plans upon discovery of wounds, with clear documentation of cleaning methods, dressing types, and monitoring protocols
4. Early escalation to hospital when wounds show signs of deterioration, particularly when professional assessment is unable to determine full extent
5. Improvement of wound swab processes including documented follow-up of results and communication with requesting GPs and prescribing clinicians
6. Better training and education of nursing staff on wound management, assessment skills, and escalation criteria
7. Implementation of regular clinical coaching and oversight for wound care documentation and decision-making
8. Enhancement of advance care planning processes with documented discussions, clear communication of goals of care, and regular review
9. Improvement of communication between RACF staff and family members regarding resident condition, treatment options, and palliative care implications
10. Implementation of weekly wound focus days to identify non-healing and newly chronic wounds
11. Adequate analgesia protocols during wound care procedures, particularly for palliative patients