Finding into death of Katrina Jane Cervasio

AI-generated summary

Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disability services group home. In the weeks before death, she displayed signs of deteriorating health including prolonged menstrual bleeding, cold-like symptoms, laboured breathing, mood changes, and reduced appetite. Her BiPAP machine (essential for her sleep apnoea) was broken on at least two consecutive nights before her death. The Disability Services Commissioner found that Yooralla failed to: maintain her BiPAP machine properly, manage her deteriorating health by escalating to medical review, provide weight management support despite significant weight gain, maintain adequate records, and deliver person-centred care. While the coroner could not definitively establish preventability, she identified the absence of timely escalation of deteriorating condition as a lost opportunity for better outcome. Yooralla subsequently implemented comprehensive improvements including specialised equipment training, health deterioration protocols, weight management programs, and enhanced documentation systems.

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