Aged care provider slammed by expert over elderly woman’s death

An investigation into the death of an elderly woman, sparked by a Sunshine Coast doctor’s concerns, has found she was subjected to ‘poor nursing care’ by her aged care provider that left her ‘screaming in pain for days’.

A coronial investigation into the death of an elderly woman, sparked by a doctor at a Sunshine Coast hospital, has found she was subjected to “poor nursing care” which led to an “outcome changing moment” prior to her death.

A coronial investigation into the death of an elderly woman, sparked by a doctor at a Sunshine Coast hospital, has found she was subjected to “poor nursing care” which led to an “outcome changing moment” prior to her death.

The Coroner’s Court of Queensland published their findings on the death of 76-year-old Diane Margaret Crowther earlier this month after it was referred for investigation by a doctor at the Sunshine Coast University Hospital.

Mrs Crowther was living in an aged care facility, requiring a ‘high care’ service as she was wheelchair-bound and suffering from a number of conditions including dementia, when staff at the facility noticed a wound on her abdomen.

The 76-year-old had been diagnosed with cellulitis in June 2023 and placed on a palliative pathway.

On August 10, when the wound on her abdomen was discovered, an old dressing was also found, which was later determined to be the cause of infection, the court documents stated.

According to the court documents, on August 30, 2023, staff at the aged care facility noticed that wound had broken the skin as Mrs Crowther “screamed and yelled” during dressing changes.

Mrs Crowther was admitted to SCUH on September 5, according to the documents, and underwent surgery days later, where a “potential element of neglect” by the aged care facility was noted.

Mrs Crowther died on September 13 from multiple organ failure due to abdominal wall cellulitis.

Senior forensic medical officer Dr Gary Hall was engaged by the Coroners Court to investigate the circumstances surrounding Mrs Crowther’s death and found there was inadequate wound care by the aged care provider, the court documents stated.

“It ought to have been reviewed and managed appropriately from the time of discovery with thorough cleaning with saline, antibiotics (if required), and attention to mitigating wound breakdown with dressings and prevention of frictional injury,” Dr Hall said.

Sunshine Coast University Hospital. Picture Lachie Millard

Dr Hall described the aged care provider’s delayed response in taking Mrs Crowther to hospital as an “outcome changing moment”.

“There was considerable deterioration of the wound by 23 August 2023. Had Mrs Crowther been referred to hospital at that time, her ulcer and infection could have been appropriately treated. This was an outcome changing moment,” Dr Hall said.

Dr Hall was also critical in his review of the aged care provider’s palliative and nursing care, which left the 76-year-old “screaming in pain” for days.

“That the wound was allowed to progress significantly over the course of over three weeks with little escalation in wound cares, developing into a large cavitating ulcer, and with Mrs Crowther screaming in pain for days due to inadequate analgesia reflects poor palliative care and poor nursing care,” Dr Hall said.

According to the coroner’s documents, the general manager at the aged care provider gave a statement revealing a “lack of clinical oversight” had impacted Mrs Crowther’s care.

“On review of the records, it appears that Mrs Crowther’s condition arose from a combination of issues including inadequate clinical assessment skills to identify when appropriate to escalate wound deterioration, lack of clinical oversight and general knowledge around wound management processes, poor continuity of care and lack of staff accountability, as well as Mrs Crowther’s strongly expressed unwillingness for hospital transfer,” the documents state.

The general manager also accepted there had been two days prior to Mrs Crowther’s hospital admission where wound care and documentation had been “missed”.

Coroner Melinda Zerner said it was likely Mrs Crowther would have had a better outcome with earlier treatment.

“Noting Mrs Crowther’s extensive medical co-morbidities, I accept on balance, with earlier surgical debridement and treatment, Mrs Crowther would likely have had a better outcome, and that the need for palliation would not have been required in the short term,” Ms Zerner said.