Finding into death of Lorraine Therese Patrick
Deceased
Lorraine Therese Patrick
Demographics
45y, female
Date of death
2011-01-05
Finding date
2012-09-18
Cause of death
Aspiration pneumonia
AI-generated summary
A 45-year-old woman with Down syndrome, epilepsy, and non-verbalisation living in a high-care community residential facility died from aspiration pneumonia. She developed cold/flu symptoms on 2 January 2011, with a coughing episode while eating. A locum was called but there was a 9.5-hour delay before attendance (6:30 pm to 4:00 am). She was admitted to hospital on 3 January with aspiration pneumonia, transferred to ICU on 4 January, and died on 5 January despite antibiotics and non-invasive ventilation. The coroner found her management appeared reasonable overall, though noted the wait for locum attendance. Key clinical lessons: early recognition of aspiration risk in vulnerable patients with swallowing difficulties; timely medical review and hospital transfer; and coordination of out-of-hours medical services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Coughing episode while eating on 2 January 2011
- Delay in locum attendance (6.5 hours from initial call at 6:30 pm to arrival at 4:00 am)
- Down syndrome with non-verbalisation affecting communication of symptoms
- Epilepsy as comorbidity
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