Coronial
VICother

Finding into death of Serafina Pirrottina

Deceased

Serafina Pirrottina

Demographics

57y, female

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2015-04-15

Finding date

2019-12-05

Cause of death

Complications of muscular dystrophy

AI-generated summary

A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility with respiratory distress and required emergency transfer to hospital. Although paramedics did not transport her mechanical ventilators to hospital as per established protocol, clinical evidence indicated this did not materially affect her outcome. Her management at the residential facility, by paramedics, and in the emergency department was deemed reasonable and appropriate. The death was not preventable; it resulted from the combined effects of cardiac failure, infection, and the progressive nature of her neuromuscular condition. The coroner found no material failures in clinical care.

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

Specialties

respiratory medicineemergency medicineparamedicinecardiology

Drugs involved

rosuvastatinramiprildiureticsparacetamollidocaineadrenalineamiodaronevassopressors

Clinical conditions

muscular dystrophycardiomyopathyheart failurepleural effusionpneumoniarespiratory acidosishypoxiarespiratory failurecardiac arrestpulmonary oedema

Procedures

manual bag-valve-mask ventilationintubation attemptfibreoptic intubationlaryngeal mask airway insertioncardiopulmonary resuscitationBPAP ventilation

Contributing factors

  • Progressive muscular dystrophy with respiratory muscle weakness
  • Newly diagnosed cardiomyopathy with moderate to severe systolic dysfunction
  • Pleural effusions secondary to heart failure
  • Suspected pneumonia with lung consolidation
  • Chronic nocturnal hypoventilation
  • Use of non-optimal mask interface despite clinical recommendations for full-face mask
  • Acute respiratory failure on night of 14-15 April 2015

Coroner's recommendations

  1. Adoption and implementation of the revised 2017 Guideline for ambulance transfers of ventilator-dependent residents from VASS to ensure clarity and consistent practice across VASS, Ambulance Victoria, and Austin Health
  2. Improved communication protocols between VASS care staff and ambulance paramedics regarding ventilator-dependent patients
  3. Ensured availability of supplementary oxygen in each VASS house rather than centralised storage
  4. Clarification and ongoing training regarding the 2007 Protocol and subsequent 2017 Guideline for all relevant staff at VASS and Ambulance Victoria
Full text

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