Inquest into the death of Alma June Green

Contributing factors

• preventable fall in radiology department due to unattended patient with heavy IV equipment
• failure to perform abdominal examination despite new onset vomiting
• failure to escalate concerns to senior surgical staff despite concerning clinical presentation
• inadequate response to family concerns about patient deterioration
• use of narcotic analgesics causing constipation
• pre-existing incarcerated bowel herniation not surgically treated before death
• inadequate investigation and documentation of fall incident

Coroner's recommendations

1. A systematic process for investigating and responding to sentinel events, such as falls, unexpected injury or death needs to be entrenched and maintained in the hospital
2. Staffing levels in the radiology department and elsewhere ought to be assessed to account for falls risk in elderly and frail patients as demographic change produces larger numbers of such patients
3. The process of assessment of falls risk during inter unit transfers is an important measure and its implementation should be encouraged and maintained
4. The observations of lay persons, usually family members, who know patients well are often accurate and may be a valuable diagnostic tool. This needs to be reinforced