Coroner's Finding: Dorothy Jean Atkins
Deceased
Dorothy Jean Atkins
Demographics
83y, female
Date of death
2017-07-09
Finding date
2024-03-07
Cause of death
meningitis with sepsis with the likely source of infection being a large and deep decubitus ulcer of the sacrum
AI-generated summary
Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling under fingernails, dystrophic toenails, and multiple pressure ulcers. Ms Atkins had not seen a GP for 12 months despite recommended monthly reviews. Her son David Baldock, her paid carer, failed to recognize or adequately treat the massive sacral ulcer despite claiming daily sponging. No aged care assessment occurred; no support services were engaged despite availability. The coroner found evidence of carer neglect including inadequate medical care, poor nutrition, neglected hygiene, and absence of prescribed medications. While not intentional or financially motivated, the neglect was reckless, resulting from ignorance and failure to act in Ms Atkins' best interests despite clear cognitive decline.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- stage 4 sacral decubitus ulcer
- severe malnutrition and weight loss to 24.5kg
- poor hygiene and incontinence
- absence of medical review for 12 months
- failure to access aged care assessment
- failure to engage support services
- inadequate carer supervision and oversight
- no medication management oversight
- cognitive decline not addressed by carers
- failure to recognize serious fall and complications
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —