Coroner's Finding: Weily, Richard Maurice
Deceased
Richard Maurice Weily
Demographics
85y, male
Date of death
2013-07-15
Finding date
2016-10-07
Cause of death
Probable pneumonia following a hip fracture (comminuted fracture of right acetabulum) sustained in a fall at RFC. Significant contributing factors: ischaemic heart disease, dementia, and Parkinson's disease.
AI-generated summary
Richard Weily, 85, with Lewy-body dementia, Parkinson's disease, and cardiac disease, was admitted to Roy Fagan Centre (RFC) mental health facility on 13 June 2013 under Mental Health Act provisions for management of acute psychiatric symptoms including agitation, confusion, and suicidal ideation. While at RFC, he fell from bed on 7 July, sustaining a comminuted acetabular hip fracture. He was transferred to hospital for orthopaedic assessment but underwent palliative care given his age and poor prognosis. He died from pneumonia on 15 July. The coroner identified significant failures in RFC's falls risk management: assessment was delayed nine days post-admission, high falls risk was not recorded on Alert Sheets or ISPs, and no falls prevention strategies were implemented prior to the fracture. The coroner also found that GP Dr R.'s prescription of haloperidol was unwise in this patient but did not contribute to death. The coroner recommended RFC undertake comprehensive review of its falls risk assessment and management processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Hip fracture from fall at RFC
- Ischaemic heart disease
- Lewy-body dementia
- Parkinson's disease
- Delayed falls risk assessment
- Falls risk not recorded on Alert Sheets
- Falls prevention strategies not implemented
Coroner's recommendations
- RFC should undertake a comprehensive review of its processes surrounding falls risk assessment and management, including: ensuring assessments are conducted promptly upon admission, properly recording identified risks on patients' ISPs and Alert Sheets, and planning, recording and implementing suitable strategies to address falls risk
Full text
Related cases
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 —