Coroner's Finding: Oates, Janet Patricia
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.
Clinical conditions
Procedures
Contributing factors
- Failure of mobility hoist due to loose and worn nyloc nut on load-bearing bolt
- Overdue annual maintenance service of hoist
- Lack of additional security measures (split pins or thread-locking adhesive) on critical fasteners
- Vertebral fractures (T1 and T4) sustained in the fall
Coroner's recommendations
- All facilities using mobility hoists should review their maintenance schedules to ensure servicing occurs at appropriate intervals to detect and prevent component failure
- Technicians responsible for servicing mobility hoists should use thread-locking adhesive (such as Loctite) and/or split pins to provide additional security to critical, load-bearing nuts and bolts
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