Deceased
Jennifer GIBBINS
Demographics
54y, female
Coroner
Coroner John Martin Murphy
Date of death
2005-12-27
Finding date
2010-01-20
Cause of death
Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of right lung lower lobe
AI-generated summary
Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by her GP, but when symptoms recurred, treatment was inadequate—Panadol was prescribed without further investigation. A three-month delay occurred before imaging was arranged in December 2005, revealing a lung mass and cardiac thrombus. Jennifer was admitted to Royal Melbourne Hospital where lung biopsy was performed, after which her condition deteriorated rapidly with severe pneumonia and sepsis developing. She died on 27 December 2005. Clinical lessons include the need for appropriate imaging investigation of persistent respiratory symptoms, particularly in vulnerable patients with communication difficulties who cannot self-advocate. Staff reliance solely on behavioural observation for health assessment was inadequate; systematic medical review and investigation should not be delayed.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
FORM 37 Rule 60(1)
FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008
Court Reference: 4723/2005 Inquest into the Death of Jennifer GIBBINS
Delivered On: , 20th January, 2010 Delivered At: Shepparton
Hearing Dates: 24 November 2009 Findings of: Mr John Martin Murphy Representation:
Place of death/Suspected death: — Parkville
FORM 37 Rule 60(1)
FINDIN G INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court Reference: 4723/2005
In the Coroners Court of Victoria at Shepparton J Mr John Martin Murphy, Coroner having investigated the death oft
Details of deceased:
Surname: GIBBINS
First name: Jennifer
AND having held an inquest in relation to this death on 24 November 2009 at Shepparton Law Courts
ind that the identity of the deceased was Jennifer GIBBINS
and death occurred on 27 December 200Sat Parkville
from
‘la Sepsis
b Bronchopneumonia complicating malignant spindle cell tumour of right lung lower lobe
in the following circumstances:
The deceased, Jennifer GIBBINS, resided at a Shared Accommodation Unit situated at 8 Wintersun Court
. Shepparton. Care was provided to Jennifer on a twenty-four hour basis. Jennifer was unable to communicate with staff verbally and staff had to rely on observations for almost all of her care needs, Jennifer's health was also assessed in this mamner,
Due to the lack of verbal communication staff had to wait until Jennifer showed signs of being unwell. Usually this meant that she would become aggressive or uncooperative.
Staff would then have to rely on asking simple questions to determine what the condition would be,
On 7 April 2005 it became apparent that Jennifer was suffering a cough and treatment was sought. The doctor prescribed a course of antibiotics which was taken. This
Signature:
action did nothing to abate Jennifer's condition and another course of antibiotics was undertaken. No other treatment was sought.
Approximately three months later a medical review of Jennifer's condition was conducted. It was found that she had another cough which was described as being moist and chesty. Panadol was prescribed for this and no further treatment was ordered.
On 29 November 2005 Jennifer had a mild temperature and was again coughing, The doctor was again contacted and again prescribed Panadol be administered. [He also asked that an appointment be made if symptoms did not abate. On 13 December 2005 such appointment was carried out, an XRay was performed and another course of antibiotics was prescribed.
Staff at the unit were contacted on 15 December 2005 by the doctor who informed them that Jennifer was required to undcrgo a CT scan. Asa result of this scan it was found that Jennifer had a mass on her right lung and blood clot in her heart, She was then admitted to hospital where she underwent some investigative procedures before being transferred to Royal Melbourne Hospital.
On 23 December 2005 Jennifer arrived at Royal Melbourne Hospital and underwent scans and a biopsy of the right lung was performed. After this procedure it appears that Jennifer's health has deteriorated sharply and has developed severe Pneumonia and Sepsis. Jennifer was declared deceased at 12:30pm on 27 December 2005.
Date:
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