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 refusing oral intake. The visiting GP documented intention to debride the ulcer on 14 December but did not proceed; she was transferred to hospital on 16 December after blood tests revealed severe hypernatraemia. She died 4 days later from infected sacral ulcer and fluid/nutritional imbalance. Clinical forensic review identified failures in communication with her Enduring Power of Attorney (daughter), inadequate involvement of speech pathology or dietetics for her swallowing/nutrition concerns, and unclear clinical decision-making about wound management timing. The aged care facility failed to maintain consistent wound charts and care plans. While her advanced cardiac disease and age were significant, earlier appropriate wound debridement and better family communication regarding her deteriorating condition could have altered outcomes.