Coroner's Finding: Smith, Molly Jessie
Deceased
Molly Jessie Smith
Demographics
75y, female
Date of death
2009-08-16
Finding date
2017-11-17
Cause of death
pyelonephritis and pneumonia
AI-generated summary
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final week at Roy Fagan Centre, Dr R. failed to recognise progressive bacterial infection presenting as fever, tachycardia, tachypnoea and other vital sign abnormalities. He misdiagnosed a urinary tract infection progressing to kidney infection as a chest infection and prescribed only oral antibiotics when intravenous therapy was required. Transfer to hospital was delayed until 15 August, by which time she was critically ill. Expert evidence established that timely recognition and appropriate antibiotic therapy by 12 August would have offered reasonable chance of survival. Nursing staff also failed to escalate concerns despite documenting deterioration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- failure to diagnose urinary tract infection progressing to kidney infection
- misdiagnosis of respiratory infection instead of kidney infection
- failure to order urgent blood tests and imaging
- inappropriate antibiotic selection and route (oral instead of intravenous)
- failure to transfer to hospital for acute medical care
- delay in recognition of clinical deterioration despite vital sign abnormalities
- failure of nursing staff to escalate concerns to senior clinicians
- inadequate policies for escalation of care in acute medical deterioration
- lack of 24-hour on-site medical cover
- telephone advice service (GP Assist) without direct clinical assessment
Coroner's recommendations
- RFC should modify the Adult Observation and Response Chart to incorporate clear instructions regarding appropriate instances for invoking GP Assist service during after-hours periods, with reference to acute/non-acute presentations and Tiers 1-4
- RFC should provide ongoing training of nurses in managing acute medical conditions including procedures for liaison with consultants or medical officers, recording of escalation, use of GP Assist service, and training in use of the Chart
- RFC should conduct a review of procedures for supervision of medical practitioners holding conditional registrations, including selection and training of supervisors and recording and retention of all supervision documentation
- RFC should implement a written policy and system to ensure persons admitted who are incapable of giving informed consent are only admitted, treated and continue residence with substitute consent of a legal guardian appointed under Guardianship and Administration Act 1995 or pursuant to a power or order under Mental Health Act 2013
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