AN INQUEST INTO THE DEATH OFEDWARD ROBERT DAVIS
Deceased
Edward Robert Davis
Demographics
88y, male
Date of death
2016-12-18
Finding date
2018-02-28
Cause of death
left frontal lobe haemorrhage due to a fall
AI-generated summary
Mr Edward Davis, an 88-year-old man with epilepsy, stroke, dementia and on anticoagulation therapy, fell onto a Stand-Up Lifter positioned directly in front of him while waiting for a second staff member to operate it. His head struck the machine's arm support, causing a left frontal lobe haemorrhage from which he subsequently died. While the fall was accidental and staff conduct was appropriate, the coroner found the impact was potentially preventable because the lifter need not have been positioned in front of the patient before both operators were present. The case highlights a systemic risk in aged care equipment setup practices and inadequate facility response to safety concerns raised by the coroner.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Stand-Up Lifter positioned in front of patient before second operator was present
- patient fall from bed edge
- anticoagulation therapy increasing bleeding risk
- brain atrophy from dementia increasing vulnerability to impact injury
- inadequate facility response to coroner's safety concerns
Coroner's recommendations
- BUPA Calwell should review and revise practices, policies, and staff training in respect of positioning sling lifters around patients prior to active deployment of equipment
- Australian Aged Care Quality Agency to receive findings for information and any action considered appropriate in relation to these types of lifters
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