Coroner's Finding: KOLAN Zygmunt
Deceased
Zygmunt Kolan
Demographics
91y, male
Date of death
2017-03-10
Finding date
2021-06-30
Cause of death
intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating recurrent falls on a background of Alzheimer's dementia
AI-generated summary
A 91-year-old man with Alzheimer's dementia died from intracranial haemorrhage following recurrent falls at a nursing home. He had multiple comorbidities including metastatic prostate cancer, metallic aortic valve replacement requiring anticoagulation, and pacemaker. He suffered two significant falls within two days while in respite care, the second causing bilateral subdural haemorrhages and other traumatic injuries. Management of anticoagulation was complicated by high clot risk from the valve versus bleeding risk from falls. The coroner found care at both hospital and nursing home was appropriate, with reasonable protective measures in place including frequent monitoring, floor mats, and low bed settings. No deficiencies in clinical management were identified.
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Specialties
Drugs involved
Clinical conditions
Contributing factors
- Alzheimer's dementia affecting mobility and cognition
- Multiple comorbidities including metastatic prostate cancer, metallic aortic valve replacement, pacemaker
- Anticoagulation therapy for metallic aortic valve creating bleeding risk
- High fall risk with unsafe gait requiring assistance
- Recurrent falls despite protective measures
Full text
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