Finding into death of Patrica June Andrew

73y · Female·end stage renal failure

Patricia Andrew, a 73-year-old woman with Down syndrome, end-stage renal failure, type 2 diabetes, and intellectual disability, was resident in a Department of Human Services community unit. She deteriorated over several days, became lethargic, and fell from her bed on 5 November 2010. She was transferred to Box Hill Hospital where cardiorespiratory arrest was imminent. Given her documented not-for-resuscitation status, she was transferred to palliative care on 7 November and died on 9 November from end-stage renal failure. The coroner found no evidence of substandard management. Clinical lessons include appropriate recognition of deterioration, timely escalation to hospital care, respect for advance care planning decisions, and appropriate transition to palliative care when curative treatment was no longer viable.