Non-inquest findings into the death of Diane Margaret Crowther

76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)

Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing left in an abdominal skin fold on 10 August 2023 was not managed with a care plan until 7 days later. The wound deteriorated significantly over 3 weeks with inadequate escalation and analgesia. By 23 August 2023, the wound was severely infected and malodourous with Mrs Crowther in severe pain—a critical moment when hospital referral should have occurred. Poor communication about goals of care, inadequate wound surveillance for a high-risk patient, and failure to escalate deteriorating wounds to hospital contributed to preventable morbidity. Earlier surgical debridement and appropriate hospital management would likely have prevented death.