Coroner's Finding: SWINGLER Yvonne Mary

86y · Female·multi-organ failure due to sepsis

An 86-year-old woman with dementia, recent stroke, and multiple comorbidities was admitted with acute delirium and paranoia, subsequently placed on an Inpatient Treatment Order. She developed sepsis secondary to staphylococcal salivary gland infection, likely triggered by her refusal to eat or drink due to paranoid beliefs. Despite intravenous hydration, antibiotics, and attempted feeding tube placement, her condition deteriorated rapidly. Given her frailty, advanced age, and multiple comorbidities, a 'not for resuscitation' decision was made in consultation with her son. She died from multi-organ failure due to sepsis. The coroner found her care was appropriate and lawful, with no preventable issues identified. Clinical lesson: early recognition of delirium in elderly patients post-stroke, consideration of underlying medical causes (infection), and early nutritional support are important, though in this case her combative presentation and refusal made intervention challenging.