Coroner's Finding: Hunter, Feryne Gaylene
Deceased
Feryne Gaylene Hunter
Demographics
75y, female
Date of death
2017-09-12
Finding date
2020-05-15
Cause of death
Airway obstruction due to aspiration occluding a permanent tracheostomy
AI-generated summary
Feryne Gaylene Hunter, aged 75, died from airway obstruction due to aspiration into her permanent tracheostomy. She had a history of subglottic stenosis, asthma, and gastro-oesophageal reflux disease with a hiatus hernia. Despite district nursing care three times weekly and two ambulance attendances on 11-12 September 2017, Mrs Hunter consistently refused assessment and hospital transport. Paramedics correctly applied capacity assessment criteria (VIRCA) on both occasions. The coroner found no preventable failures in clinical care or paramedic actions. However, documentation of refusal assessment could have been more comprehensive regarding risks and alternative pathways. The underlying clinical deterioration—coughing up clots, tracheostomy blockages, and progressive unwell state—occurred despite appropriate monitoring and advice to seek help.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Subglottic stenosis with permanent tracheostomy
- Gastro-oesophageal reflux disease with hiatus hernia
- Asthma
- Patient refusal of assessment and hospital transport
- Likely aspiration of food/gastric contents into tracheostomy
- Recent debulking and diathermy procedures with persistent coughing up of clots
Coroner's recommendations
- Ambulance Tasmania should rewrite the Refusal of Treatment / Transport Policy with appropriate legal advice to provide simple and clear guidance on how paramedics are to deal with issues relating to capacity, consent and refusal of treatment, particularly in situations of diminished capacity
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