Coronial
VICaged care

Finding into death of Winifred Jean Morffew

Deceased

WINIFRED JEAN MORFFEW

Demographics

88y, female

Date of death

2018-01-07

Finding date

2018-10-31

Cause of death

Complications of a pedestrian accident including subarachnoid haemorrhage, subdural haemorrhage and fractured humerus

AI-generated summary

An 88-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, cardiomyopathy) was struck by a reversing vehicle at low speed, sustaining subarachnoid haemorrhage, subdural haemorrhage, and fractured humerus. She was initially managed conservatively at Ballarat Base Hospital with neurosurgery consultation. Subsequently she developed acute delirium, a large bowel obstruction, and NSTEMI. She was transferred to a rehabilitation facility then back to acute care, eventually transferred to a rural hospital for palliative care where she died. Medical care provided was deemed appropriate. However, the coroner identified a significant system failure: neither hospital recognised the obligation to report this death to the coroners court—it was only detected through routine auditing by the Registry of Births Deaths and Marriages. The coroner recommended both hospitals implement training on reportable death notification obligations.

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

Specialties

emergency medicineneurosurgerygeneral surgeryorthopaedic surgeryophthalmologygeriatric medicinepalliative carecardiology

Error types

system

Clinical conditions

subarachnoid haemorrhagesubdural haemorrhagefractured humeruslarge bowel obstructionnon-st-elevation myocardial infarctionacute deliriumtype II diabetes mellitusischaemic heart diseasecardiomyopathyhypertension

Procedures

CT scan of brainCT scan of facial bonesCT scan of cervical and thoracolumbar spineCT scan of chestCT scan of left shoulderCT scan of abdomen and pelvisrepeat CT scan of brainplain x-ray of abdomenCT scan of abdomen

Contributing factors

  • Large bowel obstruction
  • Non-ST elevation myocardial infarction (NSTEMI)
  • Advanced age (88 years)
  • Multiple comorbidities including diabetes, ischaemic heart disease, cardiomyopathy, and hypertension
  • Acute delirium post-injury

Coroner's recommendations

  1. Ballarat Health Services implement training to educate clinicians on their obligations to report deaths to the Coroners Court of Victoria
  2. Ballan District Health and Care implement training to educate clinicians on their obligations to report deaths to the Coroners Court of Victoria
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