Coronial

17 results for sacral ulcer

QLDaged care2015-06-11

Ms C - Non-inquest findings

90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia

A 90-year-old woman with dementia, admitted to aged care in September 2012, developed a large necrotic sacral pressure ulcer despite nursing interventions. She was markedly dehydrated and malnourished, repeatedly ref…

general practicegeriatric medicinecommunicationdelayfentanyl
TAShospital2022-03-18

Coroner's Finding: Shields, Sandra Mary

63y · Female·sepsis and pneumonia due to immobility with sacral ulcer resulting from schizoph…

Sandra Shields, aged 63, died of sepsis and pneumonia secondary to a sacral pressure ulcer in the context of treatment-resistant catatonic schizophrenia. She was admitted to Launcest…

psychiatrygeneral medicineclozapine
NSWaged care2019-09-27

Inquest into the death of Sylvia CONFOS

87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…

87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was n…

geriatric medicinegeneral practicecommunicationsystemrozex
VICaged care2023-03-22

Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services …

geriatric medicinegeneral practicesystemcommunicationflucloxacillin
VICmental health2015-06-16

Finding into death of John Wilfred Knight

71y · Male·Sepsis due to bronchopneumonia and sacral ulcer

…viours re-emerged. Heavy sedation with haloperidol became necessary, and he developed bronchopneumonia and sacral ulcer. The coroner found the medical management, whilst potentially sub-optimal in some respects, was reas…

psychiatrygeriatric medicineolanzapine
TAShome2024-03-07

Coroner's Finding: Dorothy Jean Atkins

83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…

Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling u…

geriatric medicinepathologydiagnosticcommunicationirbesartan
SAhospital2021-11-23

Coroner's Finding: Beahl, Raymond Saxon

81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer

Raymond Saxon Beahl, 81, died of metastatic rectal adenocarcinoma complicated by an infected necrotic sacral ulcer. He was admitted to Oakden Older Persons Mental Health Service with severe dementia-related behaviou…

psychiatrypalliative carediagnosticcommunicationamoxicillin/clavulanate
VIChospital2026-02-12

Finding into death of Kristy Ann Mitchener

45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…

…c developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despite intravenous antibiotics. A pressure area was first identified on 30 June 2024 and r…

general practiceemergency medicinesystemcommunicationantibiotics
SAhospital2018-09-07

Coroner's Finding: MCBRIDE Peter James

86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer

An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury ri…

general practicegeriatric medicinediagnosticproceduralolanzapine
WAhome2016-11-22

Inquest into the Death of Maria Carmel NICEFORO

75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…

…ly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCare for approximately 9 months, during which her condi…

general practiceemergency medicinecommunicationsystem
QLDaged care2024-10-22

Non-inquest findings into the death of MH, an aged care resident

98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…

A 98-year-old woman with dementia and multiple comorbidities died from sepsis secondary to a sacral pressure ulcer that progressed to osteomyelitis while in residential aged care. The coroner identified sys…

geriatric medicinegeneral practicediagnosticsystemwarfarin
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being as…

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
NSWhospital2018-05-30

Inquest into the death of Marcia Clark

83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to …

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 seve…

geriatric medicinegeneral practicediagnosticcommunicationolanzapine
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacra…

geriatric medicinegeneral practicesystemcommunicationantibiotics
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

…vice (SRS) after hip fracture surgery. She required two-person assistance for mobility and was immobile. A sacral pressure injury developed within days of discharge and rapidly deteriorated to stage IV despite treatment.…

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
VICaged care2025-09-15

Finding into death of Arto Aaro Bohm

74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…

…iitis of pressure wounds developed while in aged care. Key clinical failures included: inadequate pressure ulcer prevention despite high-risk Waterlow scores (hourly repositioning was recommended but 4-hourly was implem…

geriatric medicinegeneral practicesystemcommunication
TASaged care2026-05-19

Coroner's Finding: de-identified BE

85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abs…

An 85-year-old man with dementia and multiple comorbidities died of sepsis caused by an infected sacral pressure ulcer that developed and deteriorated while resident at an aged care facility. Initially assessed…

geriatric medicinegeneral practicedelaymedication

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