Finding into death of Grazia Giosserano

61y · Female·Acute renal failure and dehydration in the setting of cirrhosis (secondary to hepatitis C), rib fractures and soft tissue damage sustained in motor vehicle collision (passenger)

A 61-year-old woman with cirrhosis secondary to hepatitis C sustained rib and clavicle fractures in a motor vehicle collision. She was discharged from the ED after 6 hours despite her underlying liver disease and coagulopathy. She deteriorated rapidly 3 days later with acute renal failure, dehydration and internal bleeding, dying within 2 hours of re-presentation. The coroner found that whilst Dr L.'s clinical assessment and documentation were comprehensive, optimal care required admission for pain management and observation to guard against occult bleeding in a coagulopathic patient. The coroner could not determine whether admission would have changed the outcome, but acknowledged the potential for different results. No negligence or departure from standards was found, but a different clinical decision would have been appropriate.