Non-inquest findings into the death of Mr H (3 of 3 linked pressure injury cases)
Demographics
87y, male
Date of death
2024-01-06
Finding date
2026-06-09
Cause of death
Multiorgan failure due to sepsis due to skin failure, underlying vascular dementia
AI-generated summary
An 87-year-old man with vascular dementia and stroke-related quadriplegia developed a sacral pressure injury in a residential aged care facility in December 2023. Despite care interventions, the wound rapidly deteriorated from Stage 1-2 to Stage 4 over one month. Key clinical deficiencies included: inadequate wound documentation and photography (December 9-18), delayed specialist review, and failure to escalate deterioration on December 24, 27, and 31. Mr H developed septic shock on January 5 and died in hospital January 6. The coroner found systemic failures in wound monitoring and escalation, but accepted expert evidence that the death was inevitable due to end-stage dementia. Clinical lessons include: (1) recognizing pressure injuries in dying patients as terminal wounds, not merely treatable conditions; (2) ensuring adequate end-of-life planning and family communication when prognosis becomes clear; and (3) developing clinical pathways differentiating retrievable versus terminal pressure wounds in aged care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- end-stage vascular dementia
- immobility due to quadriplegia
- multiple comorbidities (diabetes, chronic kidney disease, hypertension)
- pressure injury development
- wound infection leading to sepsis
- inadequate wound documentation and photography between December 9-18
- failure to escalate deterioration on December 24, 27, and 31
- failure to recognize terminal wound as manifestation of dying process
- inadequate end-of-life care planning and family communication
Coroner's recommendations
- Develop clinical pathways and guidelines for management of pressure injuries in residential aged care facilities, differentiating between retrievable/treatable wounds and irretrievable/terminal wounds
- Include guidance on appropriate communication with families regarding wound prognosis and goals of care
- Provide guidance on quality palliative care for residents with irretrievable pressure injuries
- Improve collaboration between public health sector and aged care services to support dignified end-of-life care within aged care facilities rather than unnecessary hospital transfers at terminal stage
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