Coronial
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Coroner's Finding: SHUEARD Braydon Adrian

Deceased

Braydon Adrian Shueard

Demographics

60y, male

Date of death

2013-03-11

Finding date

2019-08-30

Cause of death

Sepsis due to pressure ulcers due to immobility on a background of advancing frontotemporal dementia, diabetes and ischaemic heart disease

AI-generated summary

A 60-year-old man with frontotemporal dementia, diabetes, and ischaemic heart disease died from sepsis secondary to pressure ulcers while subject to a Mental Health Act inpatient treatment order. He developed sacral and heel pressure injuries while immobilised at a residential facility, despite appropriate preventive measures including repositioning, alternating pressure mattress, and wound dressing protocols. The ulcers became infected and he deteriorated rapidly, requiring hospitalisation where he received surgical debridement and medical management before transitioning to comfort care. The coroner found the care at both the residential facility and hospital to be appropriate, with no deficiencies identified. This case highlights the challenges of managing immobilised patients with complex psychiatric and medical comorbidities, and the difficulty of preventing pressure ulcers in those with advancing dementia and significant medication-induced sedation.

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

Specialties

psychiatrygeneral medicinegeneral surgerypalliative careintensive care

Drugs involved

haloperidolbenztropine

Clinical conditions

sepsispressure ulcersfrontotemporal dementiatype 2 diabetesischaemic heart diseaseHashimoto's encephalopathynecrotic woundsextrapyramidal side effects

Procedures

surgical debridementnasogastric tube insertion

Contributing factors

  • immobility secondary to medication-induced sedation and extrapyramidal side effects
  • advanced dementia with cognitive decline
  • haloperidol-induced sedation, rigidity and reduced mobility
  • infection of pressure ulcers
  • multiple comorbidities including diabetes and ischaemic heart disease
  • difficulty managing behavioural symptoms requiring high-dose antipsychotic medication
Full text

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