Coronial
VIChospital

Finding into death of Mary Una Barnett

Deceased

MARY UNA BARNETT

Demographics

71y, female

Coroner

Coroner Rosemary Carlin

Date of death

2013-10-23

Finding date

2014-07-14

Cause of death

Diffuse Lymphoid Malignancy

AI-generated summary

Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including chronic heart failure, renal impairment, diabetes, and COPD. While receiving medical care both in custody and at St Vincent's Hospital, she missed a scheduled renal clinic review in August 2013, despite plans for follow-up. The coroner noted this omission but concluded it did not contribute to her death. The case highlights the importance of robust systems to ensure continuity of specialist care for chronically ill patients in custodial settings, and the need for contracted health service providers to develop processes that do not rely solely on external appointment coordination.

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

Specialties

cardiologynephrologyrespiratory medicineoncologygeneral medicineforensic medicine

Error types

systemdelay

Clinical conditions

diffuse lymphoid malignancyhigh-grade lymphomachronic heart failurechronic kidney diseaserenal artery stenosistype 2 diabetesischaemic heart diseasehypertensionperipheral vascular diseasestrokechronic obstructive pulmonary diseasepancreatitisanaemia

Contributing factors

  • Missed renal clinic review in August 2013
  • System failure in coordinating external specialist appointments for chronically ill inmates

Coroner's recommendations

  1. Contracted health service providers such as GEO Care develop systems and processes to avoid reliance on external providers for specialist appointment coordination
  2. Monitor the provision of external appointments to ensure patient omissions do not occur in the future
Full text

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