Coronial
VIChospital

Finding into death of Grazia Giosserano

Deceased

Grazia Giosserano

Demographics

61y, female

Date of death

2008-02-01

Finding date

2014-04-17

Cause of death

Acute renal failure and dehydration in the setting of cirrhosis (secondary to hepatitis C), rib fractures and soft tissue damage sustained in motor vehicle collision (passenger)

AI-generated summary

A 61-year-old woman with cirrhosis secondary to hepatitis C sustained rib and clavicle fractures in a motor vehicle collision. She was discharged from the ED after 6 hours despite her underlying liver disease and coagulopathy. She deteriorated rapidly 3 days later with acute renal failure, dehydration and internal bleeding, dying within 2 hours of re-presentation. The coroner found that whilst Dr L.'s clinical assessment and documentation were comprehensive, optimal care required admission for pain management and observation to guard against occult bleeding in a coagulopathic patient. The coroner could not determine whether admission would have changed the outcome, but acknowledged the potential for different results. No negligence or departure from standards was found, but a different clinical decision would have been appropriate.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Coagulopathy from cirrhosis
  • Multiple rib fractures with potential for flail chest
  • Discharge home without admission for observation
  • Lack of monitoring for occult internal bleeding
  • Dehydration
  • Pre-existing liver disease

Coroner's recommendations

  1. Copy of finding provided to the family of Mrs Giosserano
  2. Copy of finding provided to Dr M. c/o Monash Health
  3. Copy of finding provided to Dandenong Hospital c/o Monash Health
  4. Copy of finding provided to Dr G.
Full text

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