Coroner's Court of Western Australia

Inquest into the Death of Maria Carmel NICEFORO

Inquest into the Death of Maria Carmel NICEFORO

Delivered on :22 November 2016

Delivered at : Perth

Finding of : Coroner King

Recommendations :Yes

That, if reasonably practicable, organisations providing home-care generate a document describing the roles and responsibilities of each person involved in a patient’s care, including where applicable the patient’s family or friends, and provide a copy of such a document to those persons at the outset of that care and from time to time as is reasonably necessary.


That, home-care providers assess their patients’ needs on an on-going basis and, where a home-care provider considers that the care it is able to provide to a patient under a home-care package cannot meet the patient’s needs, the home-care provider meet with the patient and the patients’ next of kin where appropriate to so inform the patient and to discuss the patient’s further care.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a 75 year old woman who died in Armadale Kelmscott Memorial Hospital on 7 February 2014.  She lived at home with her son and suffered from a number of age-related illnesses, including type II diabetes and ischaemic heart disease with severely impaired right ventricular function.   She had limited mobility following a hip fracture in 2010, which led to pressure sores on her heel and sacral region.  In March 2013 the deceased was granted an Extended Aged Care at Home package and was referred to KinCare Community Health Ltd, a home care agency which provided in-home care and nursing services.

On 5 April 2013 KinCare began to provide the deceased with home-care, as well as wound care for cellulitis on her lower legs and pressure sores on her sacral region. The deceased’s two daughters assisted her with meals, housework and shopping.  KinCare personal care workers attended to shower the deceased five times a week and registered nurses attended three times a week to change dressings on her wounds.  There were regular problems with KinCare’s supply of dressings, thereby requiring the deceased’s children to purchase dressings from their local chemist.  On weekends and public holidays, no care was provided by KinCare under the EACH package.  The deceased’s family was not involved in showering the deceased or in dressing her wounds.

The deceased spent most of her time sitting on a chair. KinCare nurses made clear to the deceased that her pressure sores would ultimately lead to her hospitalisation if she did not take steps to reduce the pressure on them by becoming more mobile and by using a specialised cushion.  The deceased was unwilling or unable to follow that advice.

During 2013 the deceased’s condition steadily deteriorated while she continued to receive the same level of care from KinCare under the EACH package. The deceased became doubly incontinent, which led to difficulties with wound care.  Personal care workers would wash her before nurses attended to change dressings, but the dressings would not last.   One of the KinCare nurses identified as early as July 2013 that the deceased should have been in permanent care if she was going to avoid serious health consequences from her wounds, and that her medical needs could not be met in the home-care setting.

In mid-January 2014 the deceased’s condition deteriorated more quickly. On 4 February 2014 she was taken by ambulance to Armadale Kelmscott Memorial Hospital and was admitted with a diagnosis of sepsis.   The pressure wounds on her sacral area had deteriorated rapidly since they were last dressed.  She was provided with intravenous antibiotics but died on 7 January 2014.

The Coroner found the cause of death to be organ failure due to sepsis, likely from infected pressure sores, in the context of uncontrolled diabetes mellitus and ischaemic heart disease.

There was a general agreement among parties at the inquest, including KinCare, that everyone involved in the home-care of a patient, including members of the patient’s family, should receive documentation providing clear details of his or her responsibilities. That procedure should be part of a process of on-going reviews of a patient’s condition, on both a regular basis and whenever there is a change to a patient’s condition.  The Coroner made the first recommendation in this context.

The Coroner found that home-care providers should have a means of on-going assessment of a patient’s needs. If a home-care provider considers at any stage that the care it provides to a patient is not commensurate with the level of care a patient requires, it should so inform the patient to enable the patient to make an informed decision about his or her future care.  The Coroner made the second recommendation in this context.

The Coroner found that the deceased died from infection resulting from a deterioration of her condition in circumstances where, due to choices she consciously made, the likelihood of life-threatening infection was significant. While the Coroner found that there were systemic failures in KinCare’s care and treatment of the deceased, those failures did not contribute to her death.

The Coroner found that death occurred by way of natural causes.

Catch Words: Home Care:  EACH:  Pressure wounds:   Diabetes:  Sepsis:  Natural Causes.


Last updated: 30-Apr-2019

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