Lorraineo leary 302607
Deceased
Lorraine O'Leary
Demographics
57y, female
Date of death
2007-08-04
Finding date
2009-12-01
Cause of death
Ischaemic heart disease
AI-generated summary
Lorraine O'Leary, 57, a severely disabled aged care resident (stroke survivor with right-sided paralysis, recent amputation, unable to speak), suffered burns on 3 August 2007 while smoking unsupervised in her facility's courtyard, despite staff having removed her cigarettes earlier that day. Admitted to hospital with extensive facial, chest and respiratory burns. On 4 August, developed myocardial infarction and cardiogenic shock; following discussions regarding poor quality of life, treatment was withdrawn and she died. Critical systemic failures: the facility had no smoking policy for vulnerable residents, inadequate supervision protocols, and staff could not explain how she accessed cigarettes or the secured courtyard. The coroner recommended developing a comprehensive smoking policy addressing access control and supervision for mentally/physically impaired residents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Inadequate supervision of vulnerable resident
- Lack of smoking policy for mentally and physically impaired patients
- Insufficient access control to courtyard
- Unexplained access to cigarettes
- Possible unauthorized visitor assistance with door access code
- Burns injury triggering cardiac event in pre-existing ischaemic heart disease
- No authority to search resident's room to locate cigarettes
Coroner's recommendations
- Yarra West Aged Care should develop and implement a smoking policy designed to protect patients who are mentally and/or physically impaired, addressing issues of access to cigarettes and lighters and ensuring appropriate supervision protocols are in place
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