Lorraineo leary 302607

57y · Female·Ischaemic heart disease

Lorraine O'Leary, 57, a severely disabled aged care resident (stroke survivor with right-sided paralysis, recent amputation, unable to speak), suffered burns on 3 August 2007 while smoking unsupervised in her facility's courtyard, despite staff having removed her cigarettes earlier that day. Admitted to hospital with extensive facial, chest and respiratory burns. On 4 August, developed myocardial infarction and cardiogenic shock; following discussions regarding poor quality of life, treatment was withdrawn and she died. Critical systemic failures: the facility had no smoking policy for vulnerable residents, inadequate supervision protocols, and staff could not explain how she accessed cigarettes or the secured courtyard. The coroner recommended developing a comprehensive smoking policy addressing access control and supervision for mentally/physically impaired residents.