Coroner's Finding: Dickinson, Mary Marguerite

58y · Female·pneumonia, likely aspiration pneumonia

Mary Marguerite Dickinson, aged 58, died of pneumonia on 20 January 2018 at the Roy Fagan Centre after admission with a complex scapula fracture and severe cognitive decline from alcoholic dementia. The coroner found her overall care at Royal Hobart Hospital and Roy Fagan Centre was of very good standard. However, a significant procedural issue was identified: between 9-19 January 2018, the RFC changed Mrs Dickinson's medications (ceasing seven medications, increasing pain relief dosage, and switching from rehabilitation to palliative care) without obtaining consent from her appointed Public Guardian, contrary to the guardianship order requirements. The coroner criticised the lack of guardian consultation during this critical period and recommended implementation of procedures to ensure timely consent for all medical decisions. Family concerns about care quality were found to be without substance and attributed to grief. The finding emphasises the importance of complying with guardianship oversight requirements.