Finding into death of Shirley Hill Jones
Deceased
Shirley Hill Jones
Demographics
85y, female
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.
Specialties
Error types
Drugs involved
Clinical conditions
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
- 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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