Coroner's Finding: Mrs F de-identified
Demographics
91y, female
Date of death
2015-12-08
Finding date
2018-02-05
Cause of death
pelvic haematoma arising from a fracture of the neck of the left femur sustained in a fall
AI-generated summary
A 91-year-old woman with dementia, emphysema and cognitive decline was admitted to hospital after a fall. She was assessed as high falls risk but inadequate fall prevention measures were implemented—only verbal advice to remain in bed. Despite documented dementia with marked short-term memory loss and poor insight, no physical fall prevention strategies were employed (no bed lowering, floor mats, or bed sensors). She fell from her hospital bed on day 2, sustaining a femoral neck fracture that led to pelvic haematoma and death. The coroner found this preventable, emphasizing that cognitive impairment made verbal instructions insufficient. Key lessons: comprehensive falls risk assessment must drive specific environmental and physical interventions, not reliance on patient compliance; high-risk elderly patients require active monitoring and appropriate equipment regardless of verbal directives.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- high falls risk not adequately addressed with physical interventions
- dementia with marked short-term memory loss and poor insight into care needs
- verbal instructions alone insufficient for cognitively impaired patient
- failure to implement bed lowering, floor mats, or bed sensors
- inadequate completion of Falls Risk Assessment Tool
- advanced atherosclerotic and hypertensive coronary vascular disease
- emphysema
Coroner's recommendations
- Increased use of the Falls Risk Assessment Tool and its correct completion
- Direct observations of patients with a high risk of falling
- Regular auditing of Falls Risk Assessment Tool
- Education of staff in falls assessment and action plans for all patients
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