Coroner's Finding: McKenzie, Alan John
Deceased
Alan John McKenzie
Demographics
92y, male
Date of death
2018-04-15
Finding date
2018-12-10
Cause of death
heart failure secondary to ischaemic heart disease/arrythmia aggravated by a fall with cervical neck fractures
AI-generated summary
A 92-year-old man with dementia, Alzheimer's disease and COPD died following a fall from a defective princess chair in aged care. The chair's right armrest had a worn spring mechanism that failed to lock properly, allowing it to collapse when the resident leaned on it. Staff had reported maintenance concerns but no written request was submitted. The fall caused cervical spine fractures with epidural haematoma and spinal cord compression, ultimately precipitating fatal heart failure. The death was preventable: the chair should have been removed from service when faults were identified. Critical lessons include: formal equipment maintenance reporting systems must be implemented in aged care; staff concerns about equipment must be documented and escalated; regular equipment inspection protocols are essential; and equipment with identified faults must be immediately withdrawn from use until repairs are verified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- defective princess chair with worn spring mechanism
- right armrest failed to lock properly
- chair not removed from service despite identified faults
- lack of formal written maintenance reporting system
- inadequate equipment inspection protocols
- staff verbal report of maintenance issues not documented or escalated
- cervical spine fractures (C1 and C2)
- epidural haematoma
- spinal cord compression
Coroner's recommendations
- The Home, as a matter of urgency, undertake a review of its protocols surrounding the regular inspection, maintenance and repair of its equipment, coupled with its fault reporting procedures, in the hope that it leads to the implementation of new and more effective processes which prevent a repeat of an event similar to that which befell Mr McKenzie
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