Finding into death of Margaret Alice Cook
Deceased
Margaret Alice Cook
Demographics
88y, female
Coroner
Coroner Audrey Jamieson
Date of death
2017-07-28
Finding date
2023-03-22
Cause of death
Complications of a stage 3 sacral pressure ulcer in a woman with dementia
AI-generated summary
Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SRS), a low-level care facility. Following multiple falls and hospitalizations in late 2016, she was identified as high-risk for pressure ulcers and severely malnourished (BMI 14.4). Despite being discharged back to Crofton House with documented pressure ulcer risk, the facility failed to escalate her care or provide promised pressure-relieving equipment. Her GP attended infrequently (monthly). By July 2017, her pressure ulcer had progressed to stage 3 with infection before hospital transfer. Clinical lessons include: SRS facilities must recognise when residents' care needs exceed their capacity and escalate appropriately; GPs should facilitate advance care planning and coordinate specialist wound care; and early geriatric reassessment following acute deterioration is essential to guide appropriate placement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- immobility and prolonged bed rest
- severe malnutrition (BMI 14.4 declining to 12)
- urinary and faecal incontinence
- advanced dementia (undiagnosed for most of her stay)
- failure of SRS facility to escalate care when needs changed
- inadequate pressure ulcer prevention equipment (absence of air mattresses and bed hoists despite promises)
- suboptimal GP attendance (monthly rather than weekly given complexity)
- lack of specialist wound care or registered nurse involvement
- delayed recognition of care needs exceeding SRS capacity
- absence of advance care planning and medical decision-maker appointment
Coroner's recommendations
- The Royal Australian College of General Practitioners should consider using Margaret Alice Cook's case as a case study to highlight the utility of advance health directives as part of general practice education and to reinforce GPs' obligations under the Medical Treatment Planning and Decisions Act 2016
Full text
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.