Coroner's Finding: Beahl, Raymond Saxon
Deceased
Raymond Saxon Beahl
Demographics
81y, male
Date of death
2017-01-12
Finding date
2021-11-23
Cause of death
metastatic rectal adenocarcinoma with infected necrotic sacral ulcer
AI-generated summary
Raymond Saxon Beahl, 81, died of metastatic rectal adenocarcinoma complicated by an infected necrotic sacral ulcer. He was admitted to Oakden Older Persons Mental Health Service with severe dementia-related behavioural disturbance (Tier 7 BPSD) and terminal cancer. Critical failures included: inappropriate prolonged physical restraint (up to 17 hours daily) that exacerbated pressure injuries; lack of specialised wound care when the wound nurse was unavailable; inadequate nutritional support and hydration; maximal medication dosing contributing to reduced oral intake and delirium; and absence of one-to-one nursing care. A high temperature (38.4°C) on 4 January was incorrectly attributed to pain rather than infection, delaying recognition of the infected sacral ulcer reaching Stage 4. The coroner found the death possibly preventable due to poor quality care, though the underlying malignancy was terminal. Mr Beahl endured unnecessary suffering that could have been prevented with appropriate specialised palliative and geriatric care, proper wound management, and restraint-free approaches.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inappropriate prolonged physical restraint exacerbating pressure injuries
- lack of specialised wound care management
- inadequate nutritional support and hydration
- maximal medication dosing contributing to reduced oral intake and delirium
- absence of one-to-one nursing care at Oakden
- delayed recognition of infection (temperature misattributed to pain)
- severe behavioural and psychological symptoms of dementia (Tier 7 BPSD) difficult to manage
- terminal stage metastatic cancer
- facility-wide deficiencies in staffing and care quality at Oakden
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