Deceased
Janet Patricia Oates
Demographics
83y, female
Date of death
2019-07-04
Finding date
2022-11-08
Cause of death
Hospital-acquired pneumonia caused by injuries from fall; frailty and osteoporosis contributed
AI-generated summary
An 83-year-old woman died from hospital-acquired pneumonia following spinal fractures sustained in a fall from a mobility hoist at an aged care facility. The hoist failed when the spreader bar detached due to a worn and loose nyloc nut on the critical load-bearing bolt beneath the scale unit. The hoist had not received its due annual service (last serviced May 2018, due May 2019), which represented a lost opportunity for detection and repair of the defective fastener. The scale had been serviced two months prior but that work did not include inspection of the bottom nut. Clinical lessons include ensuring maintenance schedules for critical equipment are adhered to, implementing additional security measures (split pins, thread-locking adhesive) for load-bearing fasteners, and recognising that equipment failure in aged care settings can have fatal consequences.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
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