Finding into death of CFT
Deceased
CFT
Demographics
78y, female
Date of death
2020-08-04
Finding date
2025-02-26
Cause of death
Bronchopneumonia
AI-generated summary
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multiple agencies (Mecwacare, carers, GP, OPA) documented concerns about neglect from 2017 onwards including poor continence care, malnutrition, weight loss, inadequate hygiene, and failure to attend medical appointments. Despite a VCAT guardianship order in 2019 and OPA involvement, safeguarding responses were fragmented and inadequate. The GP failed to investigate weight loss reported by CFT's niece in May 2020 and did not follow up after discovering in July 2020 that CFT had not received medications since November 2019. CFT presented malnourished, dehydrated, and hypothermic requiring palliation. The coroner identified systemic gaps in Victoria's adult safeguarding framework as a key contributing factor to this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Coronary artery atherosclerosis
- Hypothermia
- Chronic neglect and inadequate care
- Malnutrition and dehydration
- Medication non-compliance
- Failure to escalate safeguarding concerns
- Fragmented adult safeguarding system
Coroner's recommendations
- Office of the Public Advocate should conduct thorough investigations whenever allegations of neglect or abuse of represented persons are raised and a guardianship order is made by VCAT, with investigation outcomes informing guardian advocate decision-making
- Office of the Public Advocate should review training, policies, procedures and guidelines when implementing VAGO recommendations to ensure guardian advocates can appropriately assess risks of harm from neglect and unmet care needs
- Victorian Government should make appropriate funding available to the Office of the Public Advocate to implement all VAGO report recommendations
- Victorian Government should implement as a priority adult safeguarding legislation to establish functions including assessment, investigation and coordination of responses to abuse, neglect and exploitation of at-risk adults
- When framing safeguarding legislation, Victorian Government should review circumstances of CFT's case and similar cases together with recommendations from ALRC, OPA and Disability Royal Commission
- Any new adult safeguarding agencies must be adequately funded by Victorian Government to function effectively
- Victorian Government should ensure any new safeguarding agency works cooperatively with service providers to facilitate timely provision or changes to support services for at-risk adults
- Victorian Government should introduce legislation enabling adult safeguarding agencies to receive and share information timely including information about neglect with police, healthcare entities, government departments, OPA and other agencies
- Victorian Government should implement OPA recommendation to build capacity of mainstream service providers to identify and respond to abuse of at-risk adults
- Victorian Government should provide funding for community awareness, media engagement and education campaigns about any new adult safeguarding function
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —