Finding into death of Kristy Ann Mitchener

45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genetic developmental and epileptic encephalopathy and severe intellectual disability despite intravenous antibiotics

Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despite intravenous antibiotics. A pressure area was first identified on 30 June 2024 and rapidly deteriorated. Key clinical challenges included her inability to maintain adequate nutrition, contraindication for PEG tube placement, and conflicting management requirements between pressure relief (requiring supine positioning) and aspiration prevention (requiring upright positioning). Although Aruma disability support staff who dressed the wound on 4-5 July 2024 had not completed formal pressure care training, the coroner found this misstep was not causal to her death. Kristy was on an end-of-life trajectory due to her underlying medical comorbidities. The coroner identified no want of care by Aruma or Austin Hospital that caused or contributed to death, but noted Aruma has since implemented comprehensive pressure care and complex wound care training for all staff.