Finding into death of Vikki Michelle Prenc
Deceased
Vikki Michelle Prenc
Demographics
59y, female
Date of death
2021-09-21
Finding date
2023-11-24
Cause of death
Asphyxial aspiration with upper airways obstruction by vomitus
AI-generated summary
Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document completed on 14 September 2021 by locum registrar Dr S. that designated her as 'not for resuscitation or intubation', implemented without Ms Prenc's informed consent (she had delirium), without family consultation, and contrary to institutional policy. When Ms Prenc arrested on 21 September from a reversible cause (choking), resuscitation was not attempted per the GOC. The coroner found Dr S.'s handling fell well below the standard of care expected. Clinical lessons: GOC discussions must involve competent patients or appropriate decision-makers; delirium renders patients incapable of informed consent; GOC must be reviewed when cognitive capacity changes; family consultation is mandatory; institutional policies must be followed to protect vulnerable patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Goals of Care document completed without informed consent from patient with delirium
- Failure to consult family or Medical Treatment Decision Maker regarding GOC
- GOC decision made by locum registrar without appropriate senior oversight
- Failure to review GOC after patient recovered from delirium
- Do Not Resuscitate status applied to potentially reversible cardiac arrest from choking
Coroner's recommendations
- Grampians Health should review and reinforce policies regarding Goals of Care completion, particularly ensuring consultation with patients, families, and Medical Treatment Decision Makers
- Clinicians should ensure that GOC decisions are not made or implemented when patients lack capacity due to delirium or other cognitive impairment without appropriate substitute decision-makers
- GOC documents should be reviewed and revisited when patients recover capacity or when there are significant changes in medical condition
- Senior medical oversight should be required when limiting life-sustaining treatment such as resuscitation and intubation
- Locum medical staff should be supported with clear protocols and senior supervision when managing complex end-of-life care decisions
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