Finding into death of Angela Therese Thompson

Contributing factors

• Right shoulder fracture from fall in January 2012, managed non-operatively due to non-compliance with conservative treatment
• Non-compliance with medical management and treatment (refused sling, splint, investigations)
• Severe anxiety and phobia of medical environments including fear of X-rays, CT scans, and MRI scans
• Fragmented medical care provided through multiple locums rather than continuity with regular GP
• Lack of identified care coordinator or specialist to oversee and liaise between GP, hospital, and other specialists
• Inadequate access to appropriately trained medical professionals familiar with Down syndrome and associated cardiac complications
• Progressive cognitive and functional decline from dementia not matched by timely transition to high-care facility
• Challenging behaviour including aggression, agitation, sleep disruption, and wandering
• Difficulty obtaining anaesthetist services for necessary procedures due to clinician unfamiliarity with Down syndrome
• Immunocompromise due to Down syndrome making aspiration pneumonia more likely to be fatal

Coroner's recommendations

1. Recognition that people with multiple disabilities including Down syndrome and dementia require integrated, specialist-led medical coordination with an identified care coordinator to liaise between GP, hospital, and other specialists
2. Need for improved access to medical professionals trained and experienced in managing people with Down syndrome and associated complications including cardiac issues during anaesthesia
3. Earlier and more efficient consideration of transition to high-care aged care facilities when functional decline becomes evident
4. Development of systems to improve continuity of medical care rather than reliance on multiple locums