Coronial
SAhospital

Coroner's Finding: POLKLASER Irmgard Giesela

Deceased

Irmgard Giesela Polklaser

Demographics

76y, female

Date of death

2010-08-15

Finding date

2012-06-25

Cause of death

Aspiration pneumonia complicating surgery for pelvic and spinal fractures on a background of frailty, osteoporosis and cardiovascular disease

AI-generated summary

A 76-year-old woman died from aspiration pneumonia following surgery for pelvic and spinal fractures sustained in a fall on a shopping centre travelator. She fell when her husband lost control of a shopping trolley with a missing brake pad on the left rear wheel. As the trolley ascended the travelator's steeper section, the defective left wheel moved backward due to gravity while the right wheel remained fixed, causing the trolley to turn sideways and jam against the travelator frame. This forced Mr Polklaser backward onto his wife. The death was ultimately from aspiration complications in an elderly, frail patient with cardiovascular disease. The preventable incident highlights the need for proper trolley maintenance and public warnings about travelator safety.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

orthopaedic surgerytrauma surgeryemergency medicineintensive care

Error types

systemdelay

Clinical conditions

aspiration pneumoniapelvic fracturespinal fracturessacral fracturelumbar vertebral fracturesbladder injurypelvic haematomaepidural haematomarespiratory failureosteoporosiscardiovascular diseasecrush injury

Procedures

iliac artery embolisationbladder repair surgeryinternal fixation and open reduction of pelvis

Contributing factors

  • Missing brake pad on shopping trolley left rear wheel
  • Inadequate trolley maintenance and inspection
  • Trolley design allowing transport on travelators
  • Elderly patient with frailty and comorbidities
  • Aspiration during post-operative recovery
  • Respiratory failure
  • Unstable pelvis requiring complex surgery

Coroner's recommendations

  1. Minister for Business Services and Consumers to issue warnings to shoppers about risks of travelling with trolleys on travelators
  2. Minister for Industrial Relations to remind supermarkets of importance of properly maintaining their trolley fleet
  3. Minister for Industrial Relations to undertake an audit of all available CCTV footage to determine frequency of trolley-travelator incidents at all shopping centres in the State to determine if regulation, inspection or other government intervention is necessary
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