Non-inquest findings into the death of Mr O.

Contributing factors

• High falls risk not adequately managed
• Fall on 5 December 2022 not escalated or reported
• No additional falls prevention strategies implemented after second fall despite identification of risk
• Inadequate post-fall monitoring and assessment
• Environmental hazards (water jug not within reach)
• Inappropriate medication administration (aspirin and rivaroxaban) after traumatic fall with rib fractures
• Delayed ambulance response to 12 December 2022 fall
• Staffing shortages and workforce challenges
• Clinical governance gaps (missed clinical review meetings)
• Incomplete admission assessment (respite admission protocol not followed)
• Hospital-acquired pneumonia
• Acute kidney injury
• Possible aspiration

Coroner's recommendations

1. Implement a fall prevention committee and post-fall checklist in aged care facilities
2. Ensure all falls are escalated immediately to appropriate personnel and family notification
3. Reassess falls prevention strategies after each fall incident
4. Consider bed and chair sensor mats for high-risk residents
5. Ensure environmental safety measures (e.g., water and call bells within reach)
6. Implement clinical decision-making regarding medication administration following traumatic incidents (withhold anticoagulants pending medical review after trauma)
7. Maintain clinical governance meetings on schedule for falls prevention strategy discussion
8. Ensure adequate staffing levels in aged care facilities to support falls prevention
9. Complete comprehensive admission assessments even for respite admissions
10. Establish post-fall monitoring protocols and ensure adherence
11. Implement pain assessment and management plans for all residents
12. Consider geriatrician review for high-risk, complex residents (as initially referred but pending)