Finding into death of Robena May Lloyd
Deceased
Robena May Lloyd
Demographics
58y, female
Date of death
2009-08-07
Finding date
2021-09-02
Cause of death
Enterococcus faecalis sepsis and acute renal failure
AI-generated summary
Robena Lloyd, a 58-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She presented to Angliss Hospital ED on 31 July with urinary retention post-ileostomy surgery and was treated empirically for UTI with trimethoprim and discharged. On 5 August, concerned about no urine passage for 48 hours, she returned to ED. Despite abnormal sodium/potassium and being on day 5 of antibiotics, she was discharged after 7 hours without passing urine. On 6 August, a locum doctor assessed her at home and advised fluid management. She collapsed on 7 August in septic shock, dying despite resuscitation. The coronial inquest found that discharge decisions on both 31 July and 5 August were reasonable based on expert medical panel evidence regarding ED practice, though acknowledged 'overshadowing' bias may have affected her care in mainstream health systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to recognise deteriorating renal function and electrolyte abnormalities on 5 August
- discharge from ED without patient voiding urine on 5 August despite recent urinary retention
- inadequate communication of discharge instructions to carers
- absence of urine culture on 5 August despite 5-day antibiotic course
- systemic overshadowing of intellectual disability leading to potential under-recognition of sepsis
- limited training of mainstream health staff in care of people with intellectual disability
- rapid progression of urosepsis/septicaemia between 5-7 August despite normal examination on 6 August
Coroner's recommendations
- The Secretary of the Victorian Department of Health should formulate an action plan to mandate skills training for health professionals in private and public health care sectors about the health needs of people with intellectual and other cognitive disabilities, addressing the lack of specific content in nursing and medical courses
- The Victorian Health Minister should give consideration to establishment of a 15-bed facility (possibly as part of the Victorian Dual Disability Service) for in-patient services for people with dual disabilities, including intellectually disabled adults, so their medical needs can be addressed when ill
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