Finding into death of Simone Grigg
Deceased
Simone Grigg
Demographics
34y, female
Coroner
Coroner Jacqui Hawkins
Date of death
2017-11-24
Finding date
2021-07-13
Cause of death
Pneumonia in a woman with intellectual disability and asthma
AI-generated summary
Simone Grigg, a 34-year-old woman with intellectual disability and asthma, died from pneumonia. She was living in DHHS supported accommodation and attending Amicus day services. On 21 November 2017, she developed respiratory distress after receiving hay fever medication. Staff noticed deterioration but were advised to return her home rather than go directly to hospital. She was admitted to Bendigo Hospital in acute respiratory distress, intubated, and treated in ICU but died three days later. The Disability Services Commissioner identified critical failures: Amicus failed to seek urgent medical attention; DHHS inadequately managed her deteriorating health, failed to communicate medication changes to day services staff, and provided no clear communication assessment. Better communication between residential and day services, prompt medical escalation, and proper documentation of health status and medication changes could have altered outcomes.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure to seek urgent medical attention when deterioration was noted
- Inadequate communication of medication changes between DHHS and Amicus staff
- Inadequate management of deteriorating health
- Failure to provide clear communication assessment despite non-verbal status
- Inadequate documentation and monitoring of health concerns
- Delay in hospital presentation
Full text
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