Finding into death of Emma Gertrude Weidemann

Contributing factors

• Inadequate assessment of decision-making capacity beyond treatment refusal
• Failure to systematically assess family violence risk despite known risk factors
• Cognitive impairment and impulsivity in Mr Weidemann not adequately considered in discharge planning
• Limited exploration of family violence risk factors by treating clinicians
• Social worker preclusion of in-home supports without allowing other services independent assessment
• Inadequate collateral information gathering from family members expressing fear and concern
• Discharge planning focused on Mr Weidemann's autonomy rather than wife's safety
• Terminal cancer diagnosis with associated mental health deterioration
• Recent history of paranoid delusions and controlling behaviours

Coroner's recommendations

1. That Eastern Health conduct a review of clinician guidelines to ensure clearer communication between clinician and patient/family members when assessing decision-making capacity beyond the ability to refuse treatment
2. That clinical guidelines provide for any specific request for assessment of decision-making capacity be documented and communicated to relevant supporting family members where appropriate, and clarify that assessment relevant only to treatment refusal should not be assumed to apply to other decisions or situations