Coroner's Finding: SCHULZ Bertha Anna

89y · Female·Multiple organ failure with cachexia on a background of chronic lower limb ulceration, squamous cell carcinoma, lower intestinal haemorrhage, pulmonary thromboembolic disease and cardiac amyloidosis

An 89-year-old woman with chronic venous leg ulcers complicated by squamous cell carcinoma died of multiple organ failure in a nursing home. She had been under guardianship following hospitalization in January 2013 for deteriorating ulcers and behavioral changes concerning for dementia. Despite consideration of amputation, conservative wound management was pursued as clinicians deemed her unsuitable for surgery. The inquest was mandatory due to her death occurring under guardianship (death in custody), not due to clinical concerns. The case highlights challenges in managing non-compliant elderly patients with complex wounds, hearing impairment, and possible cognitive decline. Early establishment of capacity assessment and advance care planning might have clarified treatment goals earlier.