Coroner's Finding: Cobham, David Alexander
Deceased
David Alexander Cobham
Demographics
84y, male
Date of death
2015-04-23
Finding date
2016-12-19
Cause of death
aspiration pneumonia following rhabdomyolysis due to entrapment of his right arm in a bathroom hand rail
AI-generated summary
David Cobham, aged 84 with dementia, died on 23 April 2015 from aspiration pneumonia following rhabdomyolysis caused by prolonged entrapment of his right arm in a bathroom hand rail at The Lodge aged care facility. His documented care plan specifically identified his need for staff assistance during early morning showers. A motion sensor had been installed to alert staff when he was out of bed. However, these care requirements were not communicated to night shift staff, and the motion sensor had been removed without explanation. Mr Cobham became entrapped around 6:15 am but remained undiscovered for approximately two hours. Post-mortem examination indicated entrapment had lasted 1.5–3 hours, causing severe rhabdomyolysis and progressive renal failure. The coroner found the death was preventable had the documented care plan been implemented and adequate supervision provided. Key clinical lessons: communication of care plans to all staff is essential, monitoring systems must be maintained, and vulnerable elderly residents with dementia require clear supervision protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to comply with documented Plan of Care
- failure to communicate care requirements to night shift staff
- removal of motion sensor alarm without notification to care staff
- lack of procedures to maintain care plan compliance
- inadequate supervision during night shift
- prolonged time before discovery of entrapped resident (approximately 2 hours)
- patient's dementia limiting his ability to call for help
Coroner's recommendations
- Bupa should carry out an audit of all residents' Plans of Care to ensure: (1) staff responsible for compliance are aware of the contents of each Plan, and (2) strategies are in place to ensure each Plan is complied with
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —