Finding into death of Robena May Lloyd

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

1. 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
2. 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