Coronial
SAaged care

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.

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

Specialties

geriatric medicineneurosurgerypalliative care

Drugs involved

warfarin

Clinical conditions

Alzheimer's dementiametastatic prostate cancersubdural haematomasubarachnoid haemorrhageintraparenchymal haemorrhagemetallic aortic valve replacementfall risk

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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