Deceased
Kerry James Murphy
Demographics
73y, male
Date of death
2014-07-17
Finding date
2016-09-01
Cause of death
Acute subdural haematoma
AI-generated summary
Kerry James Murphy, 73, died from acute subdural haematoma following a fall in Royal Darwin Hospital's overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors—yet no falls risk policy existed in ED. After cardiac monitoring was removed, he mobilised unsupervised, fell, and struck his head. Critically, no medical review occurred post-fall, and the transfer to Darwin Private Hospital omitted documentation of the fall, fever, and neurological observations. This inadequate handover delayed detection of neurological deterioration until he was unconscious. The coroner identified three preventable failures: absence of falls risk mitigation strategies, lack of structured handover, and overcrowding. System improvements were implemented post-incident, though compliance audits showed declining adoption of falls protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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