Finding into death of Patricia Jocelyn Eve Grant
Deceased
Patricia Jocelyn Eve Grant
Demographics
83y, female
Date of death
2013-10-12
Finding date
2022-01-03
Cause of death
Aspiration bronchopneumonia in a setting of cerebral infarction
AI-generated summary
Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of epilepsy medication (March 2013), progressive immobility, untreated hallucinations and self-injury, and a likely stroke two weeks before death without medical intervention. Critically, her GP attendance dropped from monthly (2000-2009) to five visits in four years prior to death, with her last appointment 16 months before death. The coroner found her GP was positioned to identify abuse indicators but failed to proactively follow up when she discontinued care. No reminder systems existed to prompt engagement with chronically ill older patients who stop attending. The coroner recommended RACGP amend standards to encourage GPs to take action when high-risk elderly patients with chronic conditions stop attending, particularly those at risk of abuse and neglect.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Cessation of prescribed epilepsy medication in March 2013
- Severe neglect and elder abuse by family members
- Lack of medical intervention for progressive deterioration
- Cerebral infarction (stroke) approximately two weeks before death
- Inability to swallow and protect airway following stroke
- Immobility and bedbound status
- Untreated hallucinations and self-injury
- Regular aspiration of food due to dysphagia
- Family withdrawal of medical care
- Failure of GP to proactively follow up cessation of attendance
- No reminder system for chronic disease monitoring
Coroner's recommendations
- RACGP should amend the Standards for General Practices and relevant RACGP clinical guides (White and Silver Books) to encourage GPs to consider taking further action to address risks to patients who do not respond to reminders in their practice management software where those patients have chronic conditions requiring ongoing monitoring and are at risk of elder abuse including neglect.
- Victorian Government should prioritise the development and implementation of a Victorian framework of adult safeguarding laws and agencies following review of existing legislation relating to safeguarding and support for 'at-risk' adults, with regard to recommendations in chapter 14 of the Australian Law Reform Commission Elder Abuse report.
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