Inquest into the death of Savvas Epsimos
Deceased
Savvas Epsimos
Demographics
84y, male
Date of death
2014-12-12
Finding date
2016-10-20
Cause of death
Complications of large right subdural haematoma
AI-generated summary
An elderly man with cognitive impairment and multiple comorbidities fell out of bed at an aged care facility while an assistant in nursing (AIN) was absent obtaining equipment. The AIN had raised the bed to facilitate use of a patient lifter, contrary to falls prevention policy requiring low bed positioning. No crash mats were present. When discovered, the AIN moved the patient back to bed without calling emergency assistance or notifying senior nurses, contrary to incident management policy. The fall resulted in a large subdural haematoma causing death. Key lessons: beds must remain lowered for falls-risk patients; incident policies must be followed immediately after falls; supervision of AIns regarding manual handling and incident response requires review; staffing allocation for two-person assists should be formalized.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Bed raised prior to fall despite falls-risk classification
- Assistant in nursing left patient unattended while obtaining equipment
- Failure to activate emergency buzzer after fall discovery
- Failure to notify senior nurses/registered nurses immediately
- Patient moved manually before nursing assessment
- Absence of crash mats in patient's room
- Inefficient staffing allocation for two-person assists
- Non-compliance with incident management policy
Coroner's recommendations
- Staffing levels of BUPA assistants in nursing should be reviewed
- Consideration should be given to formally structuring the manner in which two-person assists are conducted, in particular regarding the raising/lowering of beds and calling for a second staff member
- Review of care plans to ensure crash mats are formally documented as part of falls prevention strategy for at-risk patients
- Review of training and compliance with incident management policy, particularly regarding the emergency buzzer protocol and notification of senior nursing staff
Full text
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