Coroner's Court of Western Australia

Inquest into the Death of Anna Maria WINTER

Inquest into the Death of Anna Maria WINTER

Delivered on :31 March 2017

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a 94 year old woman who had been diagnosed with a non aggressive cancerous growth and appeared to be otherwise relatively healthy.

The deceased was referred by her general practitioner to a specialist urologist as a result of a diagnosed vulval carcinoma, requiring the deceased to have a catheter inserted. The deceased found the indwelling catheter to be uncomfortable and on review arrangements were made for the deceased to be inserted with a suprapubic catheter.  The intention was for the deceased to be discharged home but this plan was altered after concerns the deceased be reviewed by a gynaecological oncologist for the management of her lesion.  The deceased was expected to be transferred to St John of God Hospital, Subiaco that afternoon, however, the deceased remained overnight at the Waikiki Private Hospital.

The Coroner found that the deceased should have been transferred by ambulance but instead the deceased was placed in a taxi from the Waikiki Private Hospital and travelled to St John of God Hospital, Subiaco. On arrival at the hospital a staff member assisted the deceased get out of the taxi and placed her in a wheel chair.  Unfortunately the deceased collapsed suddenly and seriously on admission.

The Coroner was satisfied the deceased’s collapse was due to a naturally occurring rupture of the deceased’s diverticulum into her peritoneal cavity spreading bacteria, followed by sepsis throughout the deceased’s abdominal organs. Due to her age and underlying heart disease the deceased’s ability to compensate this insult on her system was severely compromised and despite aggressive treatment she developed septic shock and multi-organ failure.

The Coroner found while the management of the deceased’s transfer from Waikiki Private Hospital to St John of God Hospital Subiaco was not optimal, it did not cause or contribute to the deceased’s sudden collapse and death.

Catch Words : Transport of Patients from hospital to hospital : Catheter : Natural Causes.

Last updated: 11-Apr-2017

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