Maryannroberts281 05 finding14december2010

73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that entered her bloodstream through either a pressure sore or a foot ulcer

Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provided inaccurate information to the sentencing court about care facilities available. After admission, Mary was not formally assessed for dementia and was transferred 10 times between inadequate facilities, including substandard Mulawa. A pressure sore noted in November 2004 received inadequate management. This likely seeded a fatal staphylococcal bacteremia causing endocarditis. Key failures: poor initial assessment of complex medical needs, lack of coordination between Justice Health and Corrective Services NSW, inaccurate information to court, inadequate facilities for elderly prisoners, and pressure ulcer mismanagement. Clinical lessons: thorough geriatric assessment on entry to custody, accurate information to courts about services, pressure ulcer prevention and early treatment, and robust inter-agency coordination for managing complex patients in custody.