Finding into death of Winifred Jean Morffew

88y · Female·Complications of a pedestrian accident including subarachnoid haemorrhage, subdural haemorrhage and fractured humerus

An 88-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, cardiomyopathy) was struck by a reversing vehicle at low speed, sustaining subarachnoid haemorrhage, subdural haemorrhage, and fractured humerus. She was initially managed conservatively at Ballarat Base Hospital with neurosurgery consultation. Subsequently she developed acute delirium, a large bowel obstruction, and NSTEMI. She was transferred to a rehabilitation facility then back to acute care, eventually transferred to a rural hospital for palliative care where she died. Medical care provided was deemed appropriate. However, the coroner identified a significant system failure: neither hospital recognised the obligation to report this death to the coroners court—it was only detected through routine auditing by the Registry of Births Deaths and Marriages. The coroner recommended both hospitals implement training on reportable death notification obligations.