Deceased
Judith Gaye Flynn
Demographics
72y, female
Coroner
Coroner Theakston
Date of death
2019-01-20
Finding date
2022-09-16
Cause of death
subdural haemorrhage sustained from a fall from a hospital bed on 18 January 2019
AI-generated summary
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, a history of falls, and postural hypotension. Although medical assessment and treatment were appropriate, multiple preventive measures failed: a hi-low bed was never provided despite being indicated; an Assistant in Nursing was not allocated; her family was not informed of concerning incidents to enable support; and bed rails remained raised despite hospital policy prohibiting this for confused, mobile patients. A planned relocation to a high-observation room with dedicated supervision did not occur before her fatal fall. The hospital lacked coordinated systems to implement available fall-prevention controls, though the coroner did not find these failures directly caused the fall, they collectively increased fall risk and injury severity.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
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