Deceased
Elizabeth Robertson Bell
Demographics
84y, female
Date of death
2021-05-26
Finding date
2023-08-08
Cause of death
pneumonia and fracture of the neck of right femur following a fall
AI-generated summary
Mrs Bell, aged 84, died from pneumonia and a fractured right femoral neck sustained in a fall at a residential aged care facility. She had advanced Alzheimer's disease, cognitive impairment, impulsive behaviour, and was assessed as high-risk for falls. A movement sensor alarm, which was part of her prescribed falls prevention strategy, was not in place or activated at the time of the fall. The coroner found that had the alarm been properly positioned and switched on, staff would likely have been alerted to prevent the fall. Key clinical lessons include ensuring prescribed safety devices are consistently implemented, maintaining clear communication regarding care needs, and prompt staff response to fall alerts in cognitively impaired residents at high risk of falls.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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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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