Coroner's Finding: FORD Marie Janet
Deceased
Marie Janet Ford
Demographics
84y, female
Date of death
2011-04-02
Finding date
2016-02-08
Cause of death
acute left subdural haematoma
AI-generated summary
Marie Janet Ford, 84 years old with dementia, fell from a chair at a residential aged care facility and sustained an acute left subdural haematoma. She was on warfarin for deep vein thrombosis and atrial fibrillation. Initial nursing observations were appropriate, but overnight care by an agency nurse was substandard—observations were inadequately recorded and the patient was not woken for neurological checks. The coroner found the facility's initial response appropriate but highlighted a critical gap: patients on anticoagulation who sustain minor head injuries should be referred to hospital for assessment and CT scanning. This case illustrates the particular risk of intracranial bleeding in anticoagulated elderly patients with dementia, where cerebral atrophy delays symptom recognition. Earlier hospital referral and imaging could potentially have identified the bleed while reversible.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- fall from chair in aged care facility
- anticoagulation therapy with warfarin
- dementia with cerebral atrophy
- high fall risk due to impaired mobility
- inadequate neurological observations overnight by agency nurse
- poor record-keeping by agency nurse
- failure to refer to hospital for assessment and imaging following minor head injury despite anticoagulation status
- delay in CT head scan
Coroner's recommendations
- The South Australian Minister for Health, the South Australian Minister for Ageing and the Commonwealth Minister for Health and Aged Care should consider implementation of a protocol requiring nursing facilities to refer patients following falls resulting in minor head injuries to hospital for assessment
- Hospitals receiving such patients should give consideration to carrying out a CT scan, particularly for patients on anticoagulation therapy
Full text
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