Inquest into the Death of Greeuw

AI-generated summary

Vicki Margaret Greeuw, a 45-year-old woman with schizoaffective disorder, died on 13 May 2007 at Albany Regional Hospital from aspiration of vomitus secondary to bowel obstruction due to severe faecal impaction. She had been admitted as an involuntary patient on 2 May 2007. The coroner found the death was preventable. Despite a history of constipation and being prescribed multiple medications known to cause constipation (chlorpromazine, olanzapine, benztropine, lamotrigine), no physical examination was performed during her 11-day admission and no bowel chart was implemented. Critical gaps in care included: confusion between the general practitioner and psychiatrist regarding responsibility for physical assessment under the 'shared care' model; the admitting doctor's belief he had no role unless specifically asked; and the psychiatrist's incorrect assumption that physical examinations had been conducted. The coroner emphasised that even a basic physical examination would have revealed the massively distended abdomen (large intestine dilated to 12-15cm with 2,450g of faeces). Recommendations addressed the need for timely physical examination of settled involuntary psychiatric patients, implementation of bowel charts for patients on constipating medications, and clarification of GP roles in hospital policy.

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