Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body dementia, Parkinson's disease and congestive cardiac failure

An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatraemia (sodium 149 mmol/L), a biochemical marker of dehydration risk, but this was not recognised or acted upon by her GP. A three-day food and fluid chart in July 2020 showed inadequate intake (600-700 mL on two days) but was not quantified or escalated. Documentation system changes removed prompts for calculating daily fluid totals. A locum doctor's visit on 3 October found lethargy and poor intake but failed to consider dehydration, missed-diagnosed stroke based on asymmetric tone, and mistakenly believed the patient was not for active treatment, delaying hospital transfer by 18 hours. The coroner found dehydration preventable through: recognition of June blood test abnormalities with clear fluid intake instructions to nursing staff; proper quantification of the July food-fluid chart; and earlier consideration of dehydration by the locum doctor. Key lesson: dehydration in elderly cannot be detected by clinical signs alone—only by blood testing—yet this was misunderstood by multiple clinicians and aged care staff.