Coroner's Finding: Cox, Beverley Jane
Deceased
Beverley Jane Cox
Demographics
88y, female
Date of death
2024-04-06
Finding date
2026-08-10
Cause of death
Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion
AI-generated summary
This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialist clinic, general practice, and aged care facility, she fell through the cracks. In January 2022, her pacemaker triggered an ERI alert, but due to dementia and depression, she did not respond. By April 2024, the depleted pacemaker was non-functional. She had a fall at her aged care facility and presented to hospital in cardiac failure with asystolic episodes. Her death respected her Advanced Care Plan refusing CPR. The coroner found systemic failures in the pacemaker clinic's tracking and lack of clear communication about responsibility for follow-up across services. The case highlights the need for robust systems to identify overdue patients and clearly allocate responsibility for specialist surveillance between providers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Loss to follow-up for pacemaker review after May 2019
- Failure of pacemaker clinic to schedule follow-up appointment after May 2019
- Lack of pacemaker clinic systems to identify patients overdue for review
- Pacemaker battery exhaustion (ERI alert triggered 24 January 2022, end-of-service reached 11 November 2023)
- Patient did not act on ERI alert notification due to dementia, depression, or possibly deliberate choice not to seek treatment
- Lack of clear communication and documented responsibility for follow-up between specialist clinic, general practice, and aged care facility
Coroner's recommendations
- Specialist services responsible for ongoing device surveillance must either retain responsibility for patient recall and follow-up, or clearly communicate to the patient's general practitioner that responsibility for arranging future reviews has been transferred
- Specialist outpatient services must maintain robust systems that generate follow-up appointments when clinically required, identify patients who become overdue for review, escalate unresolved non-attendance, and clearly communicate responsibility for future follow-up to the patient's nominated general practitioner and relevant residential aged care facility
- Recording of pacemaker implantation and use of reminders within electronic medical records in residential aged care clinics and general practices should be incorporated to provide additional safeguards against inadvertent oversight of reviews
Full text
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