Deceased
Cynthia Stevens
Demographics
90y, female
Date of death
2019-12-01
Finding date
2022-11-22
Cause of death
Multiple rib and pelvic fractures due to a fall from a wheelchair on sloping land
AI-generated summary
Cynthia Stevens, aged 90, died from multiple fractures sustained when her wheelchair rolled uncontrolled down a steep slope in a medical car park. The primary clinical lessons include: (1) inadequate application of wheelchair brakes—the critical wheel-lock brakes were not applied, only the weaker attendant brakes which cannot hold a wheelchair on slopes; (2) failure to recognise frailty and immobility as key risk factors requiring maximum safety precautions; (3) unsafe placement of a vulnerable elderly patient on sloping ground while unattended; (4) poor environmental design with steep car park gradients unsuitable for disabled patients; (5) inadequate signage directing patients to safer drop-off areas. Although the patient had multiple medical comorbidities (macular degeneration, emphysema, Sjögren's syndrome), the fatal fall was preventable with proper wheelchair securing procedures and safer car park design. Healthcare providers caring for elderly, mobility-impaired patients must ensure all brakes are correctly applied, patients are positioned on level ground, and supervision protocols are maintained during transitions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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