Coroner's Finding: Czerniejewski, Roswitha
Deceased
Roswitha Czerniejewski
Demographics
66y, female
Date of death
2021-11-06
Finding date
2023-10-01
Cause of death
aspiration pneumonitis and gangrenous necrosis of both feet
AI-generated summary
A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couch, and refused hospital admission or nursing home placement. Community nurses attempted wound care but were repeatedly obstructed by the patient's combative behaviour, unrealistic demands, and refusal of evidence-based dressing techniques. The patient refused to sign consent forms and discharged herself from nursing services in October 2021. She deteriorated over subsequent days, refusing food and medication, and was found dead on her couch. The coroner found nursing care was appropriate and staff were commended for their dedication despite extremely challenging circumstances.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- untreated rheumatoid arthritis
- progressive immobility
- refusal of hospital admission
- refusal of nursing home placement
- non-compliance with evidence-based wound care
- combative behaviour and verbal abuse towards carers
- refusal of appropriate analgesia options
- refusal to sign consent forms
- withdrawal from community nursing services
- deterioration over several days with refusal of food and medication
- lower limb cellulitis with advanced infection
- obesity
- living in suboptimal conditions on a couch
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