Non-inquest findings into the death of Mr B (1 of 3 linked pressure injury cases)
Demographics
86y, male
Date of death
2025-09-06
Finding date
2026-06-09
Cause of death
Multiorgan failure due to neurological failure due to Alzheimer's dementia
AI-generated summary
An 86-year-old man with advanced Alzheimer's dementia developed multiple pressure injuries while residing in aged care. A Stage 1 sacral pressure wound rapidly deteriorated to Stage 4 over two weeks despite appropriate air mattress support, repositioning and dressing changes. He developed septic shock and was transferred to hospital, dying three days later. The coroner accepted expert evidence that the pressure injury represented an inevitable part of terminal decline in dementia, not poor care. Key clinical gaps identified: (1) no clear pathway to distinguish treatable from 'terminal wounds'; (2) failure to recognize and communicate the dying process to family; (3) inadequate GP resourcing for end-of-life care in aged care. Recommendations: develop clinical guidelines for terminal wound management, improve family communication about dying process, increase palliative care support, and address opioid prescribing barriers for end-of-life care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Stage 4 sacral pressure injury
- septic shock
- severe cognitive impairment from dementia
- immobilization
- malnutrition and weight loss
- congestive cardiac failure
- probable aspiration
- osteomyelitis
Coroner's recommendations
- Development of clinical pathway/guideline for management of pressure injuries in residential aged care distinguishing between retrievable/treatable wounds and 'terminal wounds'
- Clear communication protocols with families about terminal wounds and the dying process
- Quality palliative care standards for residents with wounds established as no longer treatable
- Increased resourcing and remuneration for GPs providing end-of-life care in aged care facilities
- Address barriers to opioid prescribing by GPs in end-of-life care settings
- Collaboration between public health sector and Aged Care Quality and Safety Commission on management of irretrievable pressure injuries
Full text
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