Coroner's Finding: Czerniejewski, Roswitha

66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet

A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couch, and refused hospital admission or nursing home placement. Community nurses attempted wound care but were repeatedly obstructed by the patient's combative behaviour, unrealistic demands, and refusal of evidence-based dressing techniques. The patient refused to sign consent forms and discharged herself from nursing services in October 2021. She deteriorated over subsequent days, refusing food and medication, and was found dead on her couch. The coroner found nursing care was appropriate and staff were commended for their dedication despite extremely challenging circumstances.