Finding into death of Christopher Gerard McIntosh

Contributing factors

• Infected and necrotic diabetic foot ulcer
• Systemic sepsis
• Patient refusal of hospital transfer and inpatient admission
• Lack of formal wound care education and training despite patient self-management
• Absence of regular monitoring and clinical review (2-week gap prior to acute deterioration)
• Inadequate documentation of wound condition and clinical findings
• Delayed specialist referral to high-risk foot service
• Absence of documented intervention plan for wound care management

Coroner's recommendations

1. Health service providers develop health pathways to guide clinicians in assessment, treatment and management of patients, including 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 a patient information sheet
3. Justice Health update their system to include the wound management assessment tool and patient information sheet template to be completed by staff
4. Hopkins Correctional Centre undertake an audit of compliance with Local Plan discussion requirements, including review of frequency and documentation of case manager meetings
5. Hopkins Correctional Centre address any barriers and rectify any gaps identified by the audit