Non-inquest findings into the death of Mr W
Deceased
Mr W
Demographics
82y, male
Date of death
2022-01-20
Finding date
2024-11-20
Cause of death
sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
AI-generated summary
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was not placed on a pressure-relieving mattress on admission and was left to self-manage positional changes despite poor mobility and declining cognition. The pressure injury developed around 17 December but appropriate wound care documentation and escalation to medical staff were delayed. After transfer to a transitional care facility, the injury progressed from stage 2 to stage 4 within two weeks, complicated by equipment malfunction and documentation gaps. He developed sepsis and necrotising fasciitis requiring palliation. Clinical lessons include: immediate implementation of pressure-relief strategies for high-risk patients, proper documentation and photography of wounds, timely medical escalation, adequate handover between facilities, and equipment maintenance checks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- delayed placement on pressure-relieving mattress despite high-risk assessment
- inadequate pressure area care documentation and monitoring
- patient left to self-manage positional changes despite poor mobility and cognitive decline
- incomplete and inconsistent clinical documentation
- inadequate handover of pressure injury information between facilities
- delayed wound care assessment and management
- malfunctioning pressure-relieving mattress not promptly replaced
- lack of escalation to medical staff regarding pressure injury development
- incomplete transfer documentation and discharge summary
- gaps in inter-professional communication between nursing, allied health, and medical teams
Coroner's recommendations
- Ensure documentation meets minimum required standards through targeted training and annual audits
- Implement formal referral process to senior nurse clinicians with wound care qualifications
- Establish clear expectations regarding patient rounding and bedside clinical handover
- Review and improve transfer documentation processes
- Develop and implement standardised pressure injury risk assessment and prevention tools to avoid conflicting advice
- Ensure all pressure-relieving interventions are acknowledged and actioned by the nurse caring for the patient, not delegated to patient self-management
- Escalate development or worsening of pressure injuries to the admitting doctor
- Implement wound photography with metric scale measurements and patient consent documentation
- Conduct weekly wound reassessment as per medical practitioner direction
- Establish multidisciplinary champions for wound care within facilities
- Develop and implement malfunctioning equipment flowcharts with clear reporting and follow-up processes
- Provide inservice education on pressure relieving support surfaces and risk assessment documentation
- Implement comprehensive intake checklist for referrals to ensure current and complete clinical information transfer
- Establish escalation of care procedures for recognising and responding to acute deterioration with graded assertiveness training
- Transition medical governance from GP-led model to geriatrician-led model with senior medical officer support
- Implement afterhours nurse practitioner model and extend team leader coverage
- Conduct regular audits of all pressure relieving equipment functionality and replacement
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —