A Launceston woman died of cardiac failure after her pacemaker ran out of battery and went unchecked for nearly five years, a Tasmanian coroner has found.
Beverley Jane Cox, 88, died at Launceston General Hospital on April 6, 2024, the same day she had a fall at Regis Aged Care in Norwood where she lived in a dementia ward.
Coroner Madeleine Wilson found the fall was not what killed her.
Instead, Cox died because her pacemaker had stopped working properly.
The device had been fitted years earlier for a heart block. Her last check was on May 10, 2019, when the battery was estimated to have 4.2 years left.
No follow-up appointment was ever booked, despite the clinic marking her down for a return visit.
A battery alert triggered on January 24, 2022, warning the device needed replacing. Cox never told the clinic it had alarmed.
By the time she died, the battery voltage was extremely low and the pacemaker could not keep her heart going reliably.
At hospital, Cox had long pauses in her heartbeat. When she came around from one, she gasped for breath and said: “I want to die.”
She had a clear advance care plan refusing resuscitation and life support. Her directive stated: “I don’t want to linger. I want to be let go.”
Doctors withdrew treatment in line with her wishes and she died a short time later.
Wilson found no single system flagged that Cox was overdue.
Her GP had not discussed pacemaker reviews since 2019 and the hospital cardiology system could not identify overdue patients.
The coroner noted Cox had dementia and a history of depression and said she could not rule out that Cox had deliberately ignored the 2022 alert.
The Pacemaker Clinic has since changed its practices, now making patients book a follow-up before they leave.
Wilson said specialist services should either keep responsibility for recalling patients or clearly hand that responsibility to the patient’s GP in writing.
She stopped short of making formal recommendations and passed on her condolences to Cox’s family.
