Deceased
Ms SME
Demographics
86y, female
Coroner
McDougall
Date of death
2016-01-21
Finding date
2019-06-17
Cause of death
subdural haemorrhage due to or as a consequence of a fall
AI-generated summary
Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include: (1) The critical importance of adhering to manual handling protocols, particularly the use of slide sheets for all bed mobility in residents with documented high falls risk and specific movement care plans; (2) Staff failed to use slide sheets despite clear CP22 documentation requiring them; (3) Incomplete positioning of the resident before rolling may have contributed to the fall; (4) The bed mattress setup (king single air mattress on bariatric bed) was noted as potentially problematic by the family; (5) The facility's post-incident quality improvement initiatives (Three Second Campaign, enhanced safety observations, CP22 training) address the root cause of staff not following trained procedures despite competency. Early recognition of the subdural haemorrhage on CT and conservative management given age/comorbidities were appropriate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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