Deceased
Denise Lucina Roberts
Demographics
63y, female
Date of death
2023-05
Finding date
2024-05-15
Cause of death
Combined features of bronchopneumonia, emphysema and ischaemic heart disease on a background of a probable long lie period on the ground with hypothermia in a malnourished woman
AI-generated summary
A 63-year-old woman with depression, anxiety, liver cirrhosis, and chronic drug use died from bronchopneumonia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed a routine appointment on 16 May 2023 at her community health clinic. Her daughter expected to be contacted per a prior verbal arrangement with her former doctor, but this agreement was not documented in her medical records. The new treating doctor was therefore unaware of the notification arrangement. While the coroner could not establish that earlier contact would have prevented death, the key clinical lesson is the importance of formally documenting patient safety agreements regarding next-of-kin notification for high-risk patients who miss appointments, particularly those with complex medical and psychosocial needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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