Non-inquest findings into the death of Mr M (2 of 3 linked pressure injury cases)
Deceased
Mr M
Demographics
82y, male
Date of death
2024-01-11
Finding date
2026-06-09
Cause of death
Multiorgan failure due to neurological failure due to Parkinson's disease with associated dementia
AI-generated summary
Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly deteriorated. The coroner identified deficits in skin integrity monitoring, a delayed wound specialist referral (ordered November but not completed), delayed escalation to the GP, and late pressure relief implementation. Expert opinion concluded the wound represented an inevitable terminal decline rather than a treatable condition. Mr M died from multiorgan failure due to neurological failure from Parkinson's disease, not primarily from infection. The case highlights systemic gaps in recognizing skin failure as a dying process rather than a failure of care. Key recommendations include developing clinical pathways distinguishing terminal wounds from treatable wounds, improving recognition of skin failure as part of dementia's dying process, and supporting palliative planning in facilities to avoid unnecessary late hospital transfers and associated family distress.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Chronic pressure injuries (sacral and heel)
- Inadequate monitoring of skin integrity
- Delayed wound specialist referral (ordered 22 November 2023 but not completed)
- Delayed escalation of sacral wound concerns to GP (emails 26-27 December 2023 not reviewed)
- Late implementation of pressure-relieving mattress (16 December 2023)
- Late implementation of formal repositioning chart (27 December 2023)
- Failure to recognize terminal decline and dying process
- Advanced Parkinson's disease with dementia
- Peripheral neuropathy
- Frailty and progressive reduction in mobility
Coroner's recommendations
- Develop clinical pathway/guideline for management of pressure injuries in residential aged care facilities differentiating between retrievable/treatable wounds and irretrievable/terminal wounds
- Improve recognition of skin failure as part of terminal decline in dementia and Alzheimer's disease
- Support appropriate end-of-life care and palliative planning in residential aged care facilities to avoid unnecessary late hospital transfers
- Improve communication with families regarding end-of-life planning and agency in decision-making
- Increase funding and recompense for general practitioners providing end-of-life care in residential aged care facilities
- Address reluctance by general practitioners to prescribe opioids in end-of-life care settings
- Enhance collaboration between public health sector and aged care services for recognition and management of end-of-life care in residential aged care
Full text
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