Finding into death of Jennifer Gibbins

54y · Female·Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of right lung lower lobe

Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by her GP, but when symptoms recurred, treatment was inadequate—Panadol was prescribed without further investigation. A three-month delay occurred before imaging was arranged in December 2005, revealing a lung mass and cardiac thrombus. Jennifer was admitted to Royal Melbourne Hospital where lung biopsy was performed, after which her condition deteriorated rapidly with severe pneumonia and sepsis developing. She died on 27 December 2005. Clinical lessons include the need for appropriate imaging investigation of persistent respiratory symptoms, particularly in vulnerable patients with communication difficulties who cannot self-advocate. Staff reliance solely on behavioural observation for health assessment was inadequate; systematic medical review and investigation should not be delayed.