Finding into death of Adele Di Quinzio
Deceased
Adele Di Quinzio
Demographics
86y, female
Date of death
2016-10-17
Finding date
2020-01-30
Cause of death
Sepsis complicating sacral decubitus ulceration in the setting of recent surgical correction of fractured neck of femur (secondary to fall)
AI-generated summary
Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was immobile. A sacral pressure injury developed within days of discharge and rapidly deteriorated to stage IV despite treatment. The coroner found the facility was inadequate for her care needs, pressure injury policies were insufficient, and documentation was poor and possibly falsified. Multiple medical practitioners were involved, creating discontinuity of care. Key lessons: pressure injury prevention requires proactive surveillance and comprehensive assessment; discharge planning must match patient needs to facility capability; proper documentation is essential; and aged care facilities need robust policies and trained staff for pressure injury management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- immobility following hip fracture surgery
- inadequate pressure injury prevention strategies
- delayed recognition and escalation of deteriorating pressure injury
- insufficient staffing levels
- inadequate facility capability for high-level care needs
- poor and possibly falsified documentation
- lack of continuity of care with multiple medical practitioners
- inadequate pressure area monitoring
- failure to implement prescribed pressure relief measures
- possible malnutrition
- facility not equipped with appropriate hoisting equipment
Coroner's recommendations
- Mr Jinson Thomas, Proprietor of Adare SRS should develop and implement a policy, procedure or guideline about the prevention, identification and management of pressure injuries in their residents (and train staff accordingly)
- Ms Kym Peake, Secretary of DHHS should regularly monitor Adare SRS in relation to their service delivery to their residents relevant to the prevention, identification and management of pressure injuries in their residents
- Ms Kym Peake, Secretary of Department of Health and Human Services should develop and distribute educational material to Supported Residential Services with the aim to inform them about the importance of the prevention, identification and management of pressure injuries in their residents
- Adjunct Professor David Plunkett, Chief Executive Officer of Eastern Health, Maroondah Hospital should arrange to provide refresher training to staff responsible for admitting and discharging patients to ensure that they are aware of the differences in types of aged care facilities; such as the difference between a nursing home and supported residential service and their respective levels of care
Full text
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