Finding into death of Judith Margaret Kerr

78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneumonia and rhabdomyolysis in a woman with covid infection

A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and was exposed to extremely poor hygiene. She presented to hospital malnourished, dehydrated, and with COVID-19 pneumonia, followed by sepsis and renal failure leading to multiple organ failure and death on 1 March 2022. The pathologist stated earlier medical intervention would have improved survival chances. Key system failures included: suspension of personal care services without risk assessment; poor communication between Moorabool Shire Council and treating teams; absence of adult safeguarding mechanisms to identify and intervene in elder neglect; and inadequate monitoring by community services. The coroner reinforces recommendations for comprehensive adult safeguarding legislation in Victoria to prevent similar deaths.