Coroner's Finding: de Wit, Pauline Catherine Marie
Deceased
Pauline Catherine Marie de Wit
Demographics
53y, female
Date of death
2018-11-20
Finding date
2022-01-21
Cause of death
acutely decompensated congestive cardiac failure due to blunt traumatic injuries of the posterior chest wall, lungs and vertebral column sustained in a motor vehicle crash
AI-generated summary
A 53-year-old woman with severe intellectual disability and scoliosis died from acute decompensated congestive cardiac failure following blunt traumatic injuries sustained in a five-vehicle motor vehicle crash. She was a wheelchair-bound passenger in a disability taxi that collided with multiple vehicles during peak-hour traffic on the Midland Highway. While initially stable, she deteriorated rapidly in hospital, requiring intubation, chest drains, and inotropic support before dying despite aggressive resuscitation. The coroner found the wheelchair restraint system was compliant with standards, but the wheelchair structure itself was not engineered to withstand rear-end impact forces, causing it to collapse. Key clinical lesson: vulnerability of wheelchair-dependent patients to traumatic decompensation, and need for improved protective systems in disability vehicles.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- motor vehicle crash involving five vehicles
- high-speed rear-end collision
- wheelchair frame collapse during rear impact
- inadequate speed limit for road conditions and traffic volume
- unidentified vehicle executing unsafe lane change triggering cascade collisions
- non-functional electronic advisory sign warning of slow traffic
- steep downhill gradient limiting braking distance
- peak-hour traffic conditions
Coroner's recommendations
- Reduce speed limit to 70 km/h during peak traffic times (6:15am-9:00am Monday-Friday) and afternoon peak (3:00pm-6:00pm Monday-Friday) on Midland Highway between Kings Meadows interchange and Howick Street using variable speed signs with capacity to reduce further to 40 km/h in poor weather or accidents
- Reduce speed limit to 70 km/h on Bass Highway merge ramp onto Midland Highway
- Department of State Growth to review requirements for vehicle modifications carrying passengers with disabilities, specifically developing improved protective systems and head/neck support behind wheelchair passengers to prevent wheelchair frame collapse in rear-end impacts
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