Fenech, George - Non-inquest findings

Contributing factors

• Cervical spine injury (C1-C2 subluxation) from unwitnessed fall
• Failure to escalate acute health deterioration (7-9 November: dyspnoea, confusion, frequent urination)
• Inadequate falls prevention despite high falls risk status and previous falls
• Delayed response to toileting needs resulting in unsafe self-mobilisation
• Only two of four bed rails raised without documented restraint assessment
• Poor family communication regarding health status changes
• Inadequate clinical assessment and documentation of acute symptoms prior to fall
• Atrial fibrillation
• Coronary atherosclerosis

Coroner's recommendations

1. TriCare implemented enhanced falls risk prevention strategies including replacement of sensor alarms with bed and chair assist alarms integrated into nurse call system with automatic alerting and auditability
2. TriCare established falls risk committee with multidisciplinary membership (clinical staff, physiotherapists, occupational therapists, care attendants) meeting monthly to review policies and prevention strategies
3. TriCare provided education and training to clinical staff on importance of timely family communication when health status changes
4. TriCare implemented twice-daily clinical handovers
5. TriCare upgraded call bell systems with documented 2-minute average response times
6. TriCare provided education on clinical assessment skills, appropriate escalation procedures, and care plan documentation
7. TriCare implemented electronic medication stock level monitoring system and communication tools for agency staff
8. TriCare recruited new Clinical Manager with support from Clinical Governance Support Officers