Tilse, Therese Josephine
Deceased
Therese Josephine TILSE
Demographics
91y, female
Coroner
Mack
Date of death
2006-01-10
Finding date
2009-05-13
Cause of death
Sub-dural haemorrhage due to head injury due to fall
AI-generated summary
A 91-year-old woman was admitted to hospital after accidental paracetamol overdose and was found to have had a recent right occipital lobe infarction. While receiving appropriate care, she fell from her hospital bed at the foot of the mattress (despite raised bed rails) and suffered a fatal acute subdural haemorrhage. The coroner found the medical and nursing care to be excellent with no aspects warranting criticism. The fall was deemed a tragic accident as the patient gave no warning of her intention to leave the bed and had been medically restrained earlier. The coroner noted the patient's age (91) and reduced mobility should have made such behaviour unexpected. No preventability issues were identified in the clinical management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
Clinical conditions
Procedures
Contributing factors
- accidental paracetamol overdose at home
- recent right occipital lobe infarction
- vomiting with haematemesis
- medication effects wearing off
- patient deliberate effort to leave bed
- advanced age (91 years)
Coroner's recommendations
- Liaison officer should follow up with next of kin and hold debriefing meetings with families
- Consider lower beds with padded flooring around beds to reduce impact of falls from bed
- Patient Safety Centre should review findings and evidence to generate or refine policies preventing similar accidents
Full text
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