Coronial
VIChospital

Finding into death of Rachel Frances Piskun

Deceased

Rachel Frances Piskun

Demographics

42y, female

Coroner

Coroner Audrey Jamieson

Date of death

2023-01-11

Finding date

2025-10-17

Cause of death

Pneumonia, underlying severe cerebral palsy

AI-generated summary

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stockings were left on continuously for three days causing severe tissue damage requiring below-knee amputation. Systemic failures included inadequate pain assessment in a non-verbal patient, poor communication between clinical teams, and insufficient involvement of her carers. During her final admission in December 2022, PEG feeds were delivered by syringe instead of pump contrary to prescribed protocol. While the coroner could not establish direct causation between these errors and her death from pneumonia, significant gaps were identified in disability-competent care, pain management, and documentation. The coroner highlighted systemic neglect of people with disability in hospital settings and recommended improved monitoring of care quality for this vulnerable cohort.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral medicinepain medicinepalliative carephysiotherapyoccupational therapydieteticspathology

Error types

diagnosticmedicationproceduralcommunicationsystem

Drugs involved

morphinemidazolamhaloperidolhyoscine butylbromidehyoscine hydrobromideketamineopioids

Clinical conditions

severe cerebral palsyintellectual disabilityvisual impairmentepilepsypneumoniaaspiration pneumoniasepsispressure injuriestissue necrosisoedemacardiac issuesdeliriumliver dysfunction

Procedures

PEG feedingwound debridementskin graftingcentral line insertionbelow-knee amputationurinary catheterizationsyringe driver insertion

Contributing factors

  • Compression stockings left on continuously for three days causing tissue necrosis
  • Inadequate assessment and documentation of compression garment management
  • Failure to identify and adequately manage pain in non-verbal patient
  • Poor continuity of patient information between ED and ward
  • Inability of carers to remain with patient during hospitalization due to pandemic restrictions
  • PEG feeds delivered by syringe instead of prescribed pump method
  • Unclear feeding regime documentation on bedside chart
  • Multiple aspiration events during admissions
  • Delayed pathology testing
  • Syringe driver port positioning error affecting medication delivery
  • Incorrect syringe driver medication prescription
  • Pandemic-related constraints on access to specialist staff and operating theatres

Coroner's recommendations

  1. Western Health should explore the use of existing monitoring and reporting mechanisms such as RiskMan to identify systemic problems in the care delivered to people with disabilities
  2. Health services should implement 'disability champion/lead' models to promote knowledge, professional development and capacity-building
  3. Health services should enhance referral pathways at key intake points to recognise and respond to the needs of people with disability
  4. Development of e-learning and training packages co-designed with people with disability to promote inclusion and change attitudes
  5. Leverage work around Disability Liaison Officers in health services to include focus on attitudes towards people with disability
  6. Promote workforce development strategies for disability-competent care
  7. Include disability training in pre-service health professional qualifications
  8. Australian Government should enact a Disability Rights Act
  9. Australian Commission for Safety and Quality in Health Care should amend Australian Charter of Healthcare Rights to incorporate equitable access for people with disability
  10. Review and revise National Safety and Quality Health Service Standards to provide safe, high-quality care for people with disability
  11. Review all policies and protocols to ensure people with disability are permitted to be accompanied by support persons in health settings at all times, including during restrictions like COVID-19
Full text
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Source and disclaimer

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