Coronial
SAaged care

Coroner's Finding: SCHULZ Bertha Anna

Deceased

Bertha Anna Schulz

Demographics

89y, female

Date of death

2013-10-22

Finding date

2016-08-22

Cause of death

Multiple organ failure with cachexia on a background of chronic lower limb ulceration, squamous cell carcinoma, lower intestinal haemorrhage, pulmonary thromboembolic disease and cardiac amyloidosis

AI-generated summary

An 89-year-old woman with chronic venous leg ulcers complicated by squamous cell carcinoma died of multiple organ failure in a nursing home. She had been under guardianship following hospitalization in January 2013 for deteriorating ulcers and behavioral changes concerning for dementia. Despite consideration of amputation, conservative wound management was pursued as clinicians deemed her unsuitable for surgery. The inquest was mandatory due to her death occurring under guardianship (death in custody), not due to clinical concerns. The case highlights challenges in managing non-compliant elderly patients with complex wounds, hearing impairment, and possible cognitive decline. Early establishment of capacity assessment and advance care planning might have clarified treatment goals earlier.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Chronic venous leg ulcers with squamous cell carcinoma
  • Non-compliance with wound care and treatment
  • Behavioral disturbance and resistance to examination and care
  • Suspected dementia or paranoid psychotic illness
  • Hearing impairment limiting communication
  • Pulmonary thromboembolic disease
  • Cardiac amyloidosis
  • Lower intestinal haemorrhage
  • Cachexia
Full text

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