Finding into death of Vikki Michelle Prenc

59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus

Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document completed on 14 September 2021 by locum registrar Dr S. that designated her as 'not for resuscitation or intubation', implemented without Ms Prenc's informed consent (she had delirium), without family consultation, and contrary to institutional policy. When Ms Prenc arrested on 21 September from a reversible cause (choking), resuscitation was not attempted per the GOC. The coroner found Dr S.'s handling fell well below the standard of care expected. Clinical lessons: GOC discussions must involve competent patients or appropriate decision-makers; delirium renders patients incapable of informed consent; GOC must be reviewed when cognitive capacity changes; family consultation is mandatory; institutional policies must be followed to protect vulnerable patients.