Coronial
VICaged care

Finding into death of Shirley Hill Jones

Deceased

Shirley Hill Jones

Demographics

85y, female

Coroner

Coroner Sarah Gebert

Date of death

2021-11-02

Finding date

2024-03-28

Cause of death

Complications of a left ankle fracture (operated)

AI-generated summary

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her plaster cast and sutures—the cast remained on for 5 weeks instead of the intended 2 weeks due to communication failures between the hospital, general practitioner, and aged care facility. When the cast was eventually removed, a severe pressure injury was discovered on her left heel. Although this injury was not directly infected at the time of death, it contributed to pain, anxiety, reduced mobility, and deconditioning. Shirley subsequently experienced multiple medical complications including orthostatic hypotension, urinary tract infections, oral candidiasis, hypercalcaemia, and progressive functional decline over two months. The coroner found her death resulted from complications of the ankle fracture and its sequelae, but noted the pressure injury's development and severity may have been preventable with timely cast removal. Palliative care was appropriately commenced when further medical interventions proved futile.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

geriatric medicineorthopaedic surgeryemergency medicinegeneral practicephysiotherapypalliative carepathology

Error types

communicationdelaysystem

Drugs involved

oxycodonetrimethoprimcefalexinpregabalinmoxonidineirbesartanhydrochlorothiazideprazosinesomeprazoleoxycodone/naloxoneoxycodonemagnesium carbonateoral viscous lignocaine geltopical antifungal medication

Clinical conditions

ankle fracturepressure injury (unstageable)orthostatic hypotensionurinary tract infection (e. coli)oral candidiasisherpes simplex virus infectionhypercalcaemiaanaemiaischaemic heart diseasecerebrovascular diseasediabetes mellitus type 2deliriumphysical deconditioningdehydration

Procedures

surgical repair of left ankle fractureplaster cast applicationplaster cast removalsuture removalCAM boot fittinginsertion of indwelling urinary catheterIV fluid administrationCT brain scanvarious laboratory investigations

Contributing factors

  • Pressure injury to left heel
  • Advanced age
  • Diabetes mellitus
  • Ischaemic heart disease
  • Cerebrovascular disease
  • Hypertension
  • Orthostatic hypotension
  • Physical deconditioning
  • Reduced mobility
  • Functional decline

Coroner's recommendations

  1. Baptcare consider amending its Residential Aged Care 'Readmission from Hospital Checklist' to include a reference to confirming and documenting dates of planned follow-up care and future appointments
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