Coronial
VICaged care

Finding into death of Irene Florence Curran

Deceased

Irene Florence Curran

Demographics

79y, female

Coroner

Coroner Audrey Jamieson

Date of death

2018-11-09

Finding date

2020-07-06

Cause of death

Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure

AI-generated summary

A 79-year-old woman died from ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure, four days after discharge from hospital following a hysterectomy for endometrial cancer. Key clinical lessons include: (1) the importance of timely discharge summaries and handover documentation between acute hospitals and aged care facilities; (2) careful consideration of patient transfer timing to ensure adequate staffing and support, particularly around public holidays; (3) robust medication management systems during electronic transitions; (4) clear communication regarding end-of-life care decisions across care settings. While systemic failures in communication were identified, the coroner found they were not causal to death. Early warning signs of bowel ischaemia (abdominal pain, elevated inflammatory markers, wound infection with MRSA) were present but the underlying condition developed rapidly post-operatively in the setting of pre-existing cardiac disease.

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

Specialties

gynaecologygeneral practicegeriatric medicinepathologyforensic medicine

Error types

communicationsystemdelay

Drugs involved

oxycodonerisperidonesertralineondansetronparacetamolperindoprilfurosemidetinidazoleoxycodone

Clinical conditions

ischaemic bowelcardiomegalyleft ventricular hypertrophypneumoniachronic renal failurerenal impairmentendometrial adenocarcinomahypertensionvascular dementiaanxietydepressionMRSA infectionpost-operative anaemiasepsis

Procedures

laparotomytotal abdominal hysterectomysalpingo-oophorectomyblood transfusion

Contributing factors

  • Cardiomegaly with left ventricular hypertrophy
  • Chronic renal failure
  • Pneumonia
  • Hypoperfusion secondary to cardiac disease
  • Post-operative state
  • MRSA wound infection
  • Elevated inflammatory markers (C-reactive protein 487 mg/L)
  • Recent major abdominal surgery
  • Inadequate discharge communication between hospital and aged care facility
  • Patient transfer on eve of public holiday without adequate handover
  • Missed pre-operative antibiotic due to medication system failure

Coroner's recommendations

  1. Ballarat Health Services should reassess their system for ensuring discharge summaries are drafted and sent to relevant recipients within 24 hours post-discharge
  2. Ballarat Health Services should extend education on the importance of completing discharge summaries in a timely manner to all treating clinicians hospital-wide, not solely those on orientation
  3. Hepburn Health - Trentham Aged Care should discuss concerns relating to patient transfer on public holidays with Ballarat Health Services and establish a memorandum of understanding to ensure health and safety of future patients
  4. Hepburn Health - Trentham Aged Care should reassess the iCare® medication management system to ensure capability to enter medication prompts when dispensation through pharmacy is not required
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.