Coroner's Finding: Kettlestring, Jacqueline Collette
Deceased
Jacqueline Collette Kettlestring
Demographics
64y, female
Date of death
2021-10-01
Finding date
2025-03-31
Cause of death
acute bronchopneumonia complicating Alzheimer's dementia with head injury
AI-generated summary
A 64-year-old woman with advanced Alzheimer's dementia died from acute bronchopneumonia following a head injury sustained in an unwitnessed fall. She was under a guardianship order with special powers at the time. Following a fall on 11 September 2021, clinical examination found no obvious head injury, and given her advance directive stating she was not for intubation or CPR, no further neuroimaging was undertaken. She subsequently developed hypoactive delirium and declined over two weeks before dying. The coroner found the standard of care was appropriate in challenging circumstances and made no adverse findings. The case highlights tensions between respecting advance directives in advanced dementia and potential diagnostic uncertainty after falls, particularly when imaging is deferred based on goals-of-care discussions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- advanced Alzheimer's dementia
- unwitnessed fall
- head injury
- physical aggression and combative behaviour due to dementia
- difficulty with care interventions requiring multiple staff
- aspiration risk
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