Finding into death of Christopher Gerard McIntosh

Contributing factors

• chronic diabetic foot ulcers with poor compliance with treatment
• patient refusal of hospitalization and intravenous antibiotics
• lack of documented wound care education and training
• absence of documented follow-up on specialist (podiatrist, high-risk foot team) referrals
• poor record-keeping and lack of structured wound assessment tools
• gap of two weeks without documented wound assessment between 19 March and 4 April 2022
• delay in hospital transfer from 5 to 7 April 2022 (though severity suggests this may not have altered outcome)
• apparent absence of formalized intervention plan for wound management

Coroner's recommendations

1. Health service providers develop health pathways to guide clinicians in assessment, treatment, and management of patients, including information on referral pathways for relevant services and specialists
2. All health service providers review and update current wound management policies to include wound care management assessment tools and patient information sheets
3. Justice Health update their system to include wound management assessment tools and patient information sheet templates to be completed by staff
4. Hopkins Correctional Centre undertake an audit of compliance with Local Plan discussion requirements outlined in relevant policy, including review of frequency and documentation of case manager meetings
5. Hopkins Correctional Centre address any barriers and rectify gaps identified by the audit