Deceased
Adelina Zito
Demographics
93y, female
Date of death
2022-08-03
Finding date
2025-04-08
Cause of death
acute right lower limb ischaemia
AI-generated summary
Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite paracetamol treatment. The facility failed to obtain urgent medical review despite the patient's repeated requests for hospital transfer and family pleas for escalation. Key failures included: inadequate pain management response, lack of neurovascular assessment of the leg, failure to escalate beyond paracetamol when symptoms worsened, delayed request for urgent GP review (not sent until 31 July despite symptoms from 26-28 July), and failure to pursue alternative urgent medical pathways when AAC didn't respond promptly. When finally examined on 2 August, the limb was unsalvageable. Lessons include: recognising when simple analgesia is ineffective warrants escalation, basic vascular assessment by nurses should occur during routine care, and multiple escalation pathways should be pursued when initial requests fail.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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