VIChospital

Finding into death of CFT

Deceased

CFT

Demographics

78y, female

Coroner

State Coroner Judge John Cain

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. Report an inaccuracy.

Specialties

geriatric medicinegeneral practicerespiratory medicinepsychiatrypathology

Error types

diagnosticsystemdelaycommunication

Clinical conditions

bronchopneumoniahypothermiaseptic shockcoronary artery atherosclerosischronic schizophreniaintellectual disabilitydementiatype 2 diabetesoesophagitismalnutritiondehydrationpressure ulcers

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

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