Coroner's Finding: Cohen, Yvonne Dawn
Deceased
Yvonne Dawn Cohen
Date of death
2018-02-21
Finding date
2018-11-05
Cause of death
pneumonia
AI-generated summary
Yvonne Dawn Cohen died of pneumonia six days after discharge from North West Regional Hospital. She had been admitted twice for abdominal pain, vomiting and diarrhoea. The coroner found that clinical care fell short of acceptable standards. Key failures included: staff failing to recognise the significance of her rapid weight loss (13.6kg over 139 days), poor quality clinical assessment, and discharge without a diagnosis. These clinical oversights likely delayed recognition of her underlying condition and appropriate management. The case highlights the importance of thorough assessment of weight loss, particularly when rapid, recognising patterns that may indicate serious underlying pathology, and ensuring patients are not discharged without a clear diagnosis and management plan.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- failure to recognise significance of rapid weight loss
- poor quality clinical assessment
- discharge without diagnosis
- inadequate diagnostic workup
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