Coroner's Finding: AUSTIN Grant Aaron

Contributing factors

• Intellectual disability affecting communication and cooperation with medical procedures
• Morbid obesity complicating physical examination, venous access, and airway management
• Failure to recognize Wernicke's encephalopathy due to atypical presentation masked by intellectual disability, obesity, and psychiatric diagnosis
• Inadequate communication of endoscopy findings (Helicobacter pylori infection) to psychiatrist
• Over-attribution of symptoms to psychiatric causes without adequate exploration of organic pathology
• Discontinuation of one-on-one nursing care without clear documentation or handover communication
• Difficulty obtaining cooperation with oral medications and intravenous access
• Prolonged period of malnutrition and dehydration preceding death
• Lack of formalized procedures for ordering and revoking nursing specials

Coroner's recommendations

1. Department of Health should consider options to ensure accurate and faithful dissemination of information between medical practitioners involved in care of intellectually disabled patients, particularly regarding test results and clinical findings
2. Royal Adelaide Hospital should conduct a review of the system of nursing specials, including: circumstances in which specials can be revoked, by whom, documentation required to authorize revocations, and a system for recording such documentation in patient medical records