Coroner's Finding: MORGAN Beryl Jean

Contributing factors

• failure to recognize severe dehydration despite clinical signs
• delayed medical review and inadequate initial assessment by GP
• inappropriate communication method (intramail) for urgent matters
• cursory clinical examination by Dr G. without blood testing
• failure to transfer to hospital earlier
• inadequate monitoring of fluid intake in aged care facility
• heavy workload and stress experienced by treating GP

Coroner's recommendations

1. Develop written strategies for aged care facilities to ensure recognition of deteriorating residents, including circumstances requiring medical assistance and hospital transfer, with emphasis on hydration monitoring and proper record-keeping
2. Develop written strategies for aged care facilities to avoid undue reliance on urinalysis for hydration assessment and to use telephone communication (not email/intramail) for urgent matters with medical practitioners
3. Australian Medical Association should alert members, particularly rural practitioners and those in aged care, to carefully consider dehydration in deteriorating elderly patients, avoid reliance on clinical impression alone, and conduct blood testing to assess hydration status