Deceased
Valerie KELLY
Demographics
67y, female
Coroner
Coroner Jenkin
Date of death
2016-09-24
Finding date
2020-04-02
Cause of death
bronchopneumonia and acute liver failure on a background of liver cirrhosis and hepatocellular carcinoma in a woman with atherosclerotic cardiovascular disease and recent fractured neck of femur treated palliatively
AI-generated summary
Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's Prison when she fell on 2 June 2016, fracturing her femoral neck. During her 15-month incarceration, several clinical management gaps were identified: no formal falls risk assessment despite multiple risk factors; failure to follow up a semi-urgent hepatology referral that was not received at the prison; and incomplete investigation of rectal bleeding. However, the coroner found her overall medical management adequate and that these issues did not contribute to her death. Key clinical lessons include the importance of formal risk assessment documentation, systematic follow-up of external referrals, and screening protocols for cirrhosis patients. Improvements implemented post-death include cirrhosis care plan templates and staff education on liver disease screening.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
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