Inquest into the Death of Barnes
Deceased
Donna Lillian BARNES
Demographics
50y, female
Date of death
2007-09-19
Finding date
2011-04-21
Cause of death
acute heart failure in association with acute on chronic obstructive airways disease (recent influenza A infection), focal coronary atherosclerosis and morbid obesity
AI-generated summary
Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic obstructive airways disease (influenza A infection), focal coronary atherosclerosis, and obesity on 19 September 2007 at Graylands Hospital. She had developed flu-like symptoms on 12 September 2007 and was prescribed antibiotics by Dr K., though she refused chest X-ray. After 17 September 2007, medical documentation ceased despite her ongoing respiratory symptoms. No medical assessment occurred in the week before her death despite significant risk factors. The coroner found her care generally reasonable but identified deficient record-keeping, lack of daily progress notes, and a medication chart incorrectly documenting medications given after her death. The hospital subsequently implemented improved documentation policies and physical health monitoring for mental health patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- influenza A infection
- chronic obstructive airways disease
- focal coronary atherosclerosis
- morbid obesity
- heavy smoking
- poor mobility and immobility since 2000
- lack of medical reassessment after initial treatment
- deficient record-keeping and documentation
Coroner's recommendations
- Graylands Hospital take steps to ensure that medication charts accurately reveal the giving of medications and that the charts not be written up in advance or at a time when medications have not been provided to patients
Full text
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