Redmond, Elaine

Contributing factors

• medication administration error - rivaroxaban continued despite hospital cessation
• poor medication reconciliation at care transition
• use of outdated GP medication chart instead of hospital discharge medication order
• inadequate neurological observations at aged care facility
• discharge to aged care respite rather than acute hospital for monitoring of intracranial injury
• failure to identify deterioration early due to lack of Glasgow Coma Scale monitoring
• anticoagulation exacerbating intracranial bleeding

Coroner's recommendations

1. Review medication management and reconciliation procedures at aged care facilities, particularly at care transitions
2. Implement mandatory use of single authoritative medication source post-discharge to prevent use of superseded medication charts
3. Establish clear protocols for neurological observation and Glasgow Coma Scale monitoring in aged care for patients with intracranial injuries
4. Consider acute hospital admission rather than aged care placement when close neurological monitoring is essential
5. Ensure discharge summaries clearly highlight medication changes, particularly cessation of anticoagulants
6. Improve handover and communication of clinical plans between acute hospitals and aged care facilities