Coroner's Finding: Fowler, Alice Mary

Contributing factors

• advanced age (91 years)
• dementia
• documented high fall risk status (assessed October 2015)
• impaired hearing
• poor balance and mobility
• advanced atherosclerotic and hypertensive coronary vascular disease
• emphysema
• multiple falls on day prior to hospital fall
• systemic failure to complete Falls Risk Assessment Tool (FRAT)
• lack of sitter availability
• ward environment layout constraints

Coroner's recommendations

1. Elderly patients admitted to hospital following a fall should automatically be deemed a 'high fall risk' until proven otherwise through completion of formal assessment
2. All reasonable steps should be taken to mitigate against fall risk immediately upon identification that an elderly person has had a fall and is admitted
3. The hospital (RHH) has already implemented improvements including: education of staff in FRAT and PARIS form use; reduction of time limit for form completion from 24 hours to 8 hours post-admission; development of a transfer form for changes in patient condition; increased availability of sitters; development of electronic red dot system for mobility assessment