Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her plaster cast and sutures—the cast remained on for 5 weeks instead of the intended 2 weeks due to communication failures between the hospital, general practitioner, and aged care facility. When the cast was eventually removed, a severe pressure injury was discovered on her left heel. Although this injury was not directly infected at the time of death, it contributed to pain, anxiety, reduced mobility, and deconditioning. Shirley subsequently experienced multiple medical complications including orthostatic hypotension, urinary tract infections, oral candidiasis, hypercalcaemia, and progressive functional decline over two months. The coroner found her death resulted from complications of the ankle fracture and its sequelae, but noted the pressure injury's development and severity may have been preventable with timely cast removal. Palliative care was appropriately commenced when further medical interventions proved futile.