Deceased
Patricia Nina George
Demographics
81y, female
Date of death
2002-07-27
Finding date
2006-05-22
Cause of death
aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphysema) and congestive cardiac failure
AI-generated summary
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay occurred when her initial request (5:45 am) was cancelled due to lack of staff to accompany her as a detained patient, then rebooked at 6:20 am with ambiguous priority designation. The ambulance dispatch was further delayed by a shift changeover policy. She was not transported until 7:41 am and died at Royal Adelaide Hospital by 11:20 am. Key failures included: inadequate communication between nursing and ambulance service about clinical urgency, lack of medical input into priority designation, lost/destroyed ambulance request records, and critically deficient investigation (most witnesses interviewed 3+ years post-event, investigation took three years). The coroner found the investigation hampered by systemic delays in Adelaide CIB prioritisation of deaths in custody inquiries, preventing timely identification and rectification of procedural failures.
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Specialties
Error types
Drugs involved
Clinical conditions
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