Inquest into the death of Marcia Clark

83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to infected sacral pressure sore with probable sacral osteomyelitis and early bronchopneumonia)

Mrs Clark, 83, died from severe malnutrition and infection including septicaemia from an infected sacral pressure ulcer that had existed for 7 months. She was admitted to hospital in a deplorable state with severe pressure sores, contractures, and evidence of prolonged neglect. Her daughter Nardia was her sole carer and appeared overwhelmed and possibly struggling with her own health. Dr D. saw Mrs Clark only ~10 times over 3 years, mostly seeing Nardia without the patient present. Deficient medical records failed to document bed sores appropriately, explore non-compliance with recommended treatment, or conduct home visits. A proposed home care referral was inadequately followed up. Earlier recognition of Mrs Clark's deterioration through thorough documentation, proactive home assessment, and escalation to aged care services could potentially have prevented this death.