Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stockings were left on continuously for three days causing severe tissue damage requiring below-knee amputation. Systemic failures included inadequate pain assessment in a non-verbal patient, poor communication between clinical teams, and insufficient involvement of her carers. During her final admission in December 2022, PEG feeds were delivered by syringe instead of pump contrary to prescribed protocol. While the coroner could not establish direct causation between these errors and her death from pneumonia, significant gaps were identified in disability-competent care, pain management, and documentation. The coroner highlighted systemic neglect of people with disability in hospital settings and recommended improved monitoring of care quality for this vulnerable cohort.