Deceased
Janis Mary Proctor
Demographics
56y, female
Date of death
2008-02-22
Finding date
2012-04-13
Cause of death
multi-organ failure complicating severe burns on a background of alcoholic liver disease and alcohol-related cerebellar disease
AI-generated summary
A 56-year-old woman with alcoholic liver disease, cerebellar atrophy, and marked mobility impairment suffered fatal full-thickness burns (75% TBSA) from scalding shower water at Flinders Medical Centre. She was left unattended in a shower while seated on a commode chair, despite documented difficulty extracting herself from chairs and known water temperature fluctuations in the ward. The water temperature unexpectedly increased beyond safe levels. Clinical lessons include: careful risk assessment of patient mobility before shower activities, continuous supervision of high-risk patients during bathing, prompt communication about infrastructure failures (inoperative call bells), and consideration of thermostatic mixing valves to prevent temperature fluctuations. The coroner found the death probably preventable had a carer remained present during showering.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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