Coroner's Finding: Cox, Beverley Jane

88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion

This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialist clinic, general practice, and aged care facility, she fell through the cracks. In January 2022, her pacemaker triggered an ERI alert, but due to dementia and depression, she did not respond. By April 2024, the depleted pacemaker was non-functional. She had a fall at her aged care facility and presented to hospital in cardiac failure with asystolic episodes. Her death respected her Advanced Care Plan refusing CPR. The coroner found systemic failures in the pacemaker clinic's tracking and lack of clear communication about responsibility for follow-up across services. The case highlights the need for robust systems to identify overdue patients and clearly allocate responsibility for specialist surveillance between providers.