Deceased
Adele Di Quinzio
Demographics
86y, female
Coroner
Coroner Jacqui Hawkins
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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