Coroner's Finding: Bugg, Margaret Evalina
Deceased
Margaret Evalina Bugg
Demographics
89y, female
Date of death
2015-12-30
Finding date
2017-06-12
Cause of death
pneumonia and acute renal failure following a fractured right femur due to a fall while being transported by a stand-up lifter
AI-generated summary
Margaret Evalina Bugg, aged 89, died from pneumonia and acute renal failure following a spiral fracture of her right femur sustained during a fall from a stand-up lifter on 17 December 2015. A mobility assessment in October 2015 had determined she required a full hoist for all transfers due to inability to weight-bear safely, yet on the day of the incident two experienced carers used a stand-up lifter instead. A strap detached during transfer, causing her to fall. The fracture was not diagnosed when she presented to hospital that day; an x-ray of her right leg was not performed. Six days later imaging revealed the fracture, but comfort care was chosen given her age and health status. The coroner found serious concerns about Yaraandoo's systems for ensuring staff compliance with individualised care plans, and made recommendations for comprehensive review of these practices.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- use of stand-up lifter contrary to mobility assessment requiring full hoist
- strap detachment from hoist during transfer
- operator error in hoist use
- failure to diagnose right femur fracture on initial ED presentation
- inadequate staff compliance with individualised care plans
- failure of systems to ensure staff awareness of care plan requirements
Coroner's recommendations
- Yaraandoo should carry out a comprehensive review of its practices with a view to reducing the risk of staff members failing to comply with patient care plans
- Any recommended system changes should be implemented urgently
Full text
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