Coroner's Finding: McNeair, Jacqueline
Deceased
Jacqueline McNeair
Demographics
79y, female
Date of death
2018-12-04
Finding date
2020-07-27
Cause of death
subdural haematoma following mechanical fall with head strike
AI-generated summary
A 79-year-old woman with multiple comorbidities including diabetes, peripheral neuropathy, and previous partial foot amputation fell backwards in a hospital toilet on 23 November 2018, striking her head on a sink and floor. She sustained a catastrophic subdural haematoma and died 11 days later. The coroner found the care provided was adequate and appropriate, with fall risk appropriately assessed at level two requiring one-staff assistance. While the patient's progressive instability and peripheral neuropathy increased fall risk, the coroner accepted expert opinion that falls in elderly hospitalised patients with multiple risk factors are often not reasonably preventable. No clinical errors or supervision failures were identified. The fall was deemed unavoidable despite complex medical needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- frailty
- poor mobility
- impaired vision
- impaired balance
- peripheral neuropathy
- diabetic complications
- advanced age
- progressive deterioration in stability
Coroner's recommendations
- LGH replaced the hinged toilet door with an electronic sliding door operated by button panel following identification that door weight may have been a contributing factor to the initial fall on 8 August 2018
Full text
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