Coroner's Finding: Iris Conyngham
Deceased
Iris Conyngham
Demographics
91y, female
Date of death
2009-10-15
Finding date
2011-05-20
Cause of death
traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a result of a fall
AI-generated summary
91-year-old admitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 45 minutes before being discovered semi-conscious. The fall caused traumatic subarachnoid haemorrhage and subdural haematoma; she died the following day at Royal North Shore Hospital. Despite discharge summary documenting high falls risk, thickened fluid requirement, and recent multiple falls, the admitting nurse failed to implement basic falls prevention (bed rail left down), provided regular tea despite dietary restriction, and did not immediately recheck a dangerously elevated blood pressure (203/74). The coroner found the nurse's evidence unreliable and criticized her professionalism. The aged care operator never investigated the incident or reported it to regulators. Coroner recommended review of the nurse's practice and mandatory root cause analyses for all aged care deaths following traumatic events.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- bed rail left down despite high falls risk status
- failure to implement falls prevention measures
- inadequate monitoring after admission
- failure to provide appropriate diet (regular tea when thickened fluid required)
- failure to immediately recheck high blood pressure reading
- lack of proper admission assessment
- no investigation or review by facility of the incident
Coroner's recommendations
- NSW Nurses and Midwives Registration Board to review the professionalism of the care that Sister L Pederson gave to Iris Conyngham on 14 October 2009
- Commonwealth Department of Health and Aging to review the response of Baptist Community Services to the fatal fall of Iris Conyngham at Bennelong House on 14 October 2009
- All aged care facilities to undertake a Root Cause Analysis of all deaths and hospitalizations that occur following a traumatic event within the facility
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