Finding into death of Colleen Mary Chapman

59y · Female·Myocardial infarction secondary to ischaemic heart disease

Colleen Mary Chapman, a 59-year-old woman with intellectual disability living in a community residential unit, died of myocardial infarction secondary to ischaemic heart disease, with WHO Class IV obesity as a contributing factor. She had been treated for a recent myocardial infarction in December 2019 and was on anticoagulation therapy. The Disability Services Commissioner identified that Ms Chapman lacked a weight management plan despite her morbid obesity, and was frequently provided with unhealthy foods. Key clinical lessons include the importance of comprehensive health management plans for vulnerable populations, regular review of specific health management plans, advocacy for appropriate allied health supports (dietetics), and systematic weight management in patients with obesity and cardiovascular disease risk factors. The case highlights systemic gaps in disability service coordination and the need for multidisciplinary care planning including nutrition support.