Deceased
Peter Blackwell Harris
Demographics
75y, male
Date of death
2020-05-09
Finding date
2023-09-12
Cause of death
pneumonia and head injury from fall
AI-generated summary
Peter Harris, aged 75, was admitted with behavioural disturbance and hyponatraemia (low serum sodium of 124 mmol/L). Initial clinical assessment did not identify falls risk. After 4 days, he fell backwards suddenly while standing in the corridor despite a care assistant being present. He sustained severe head injury with subdural haematoma and skull fractures, developed aspiration pneumonia, and died on 9 May 2020. The fall's cause (hyponatraemia versus cardiac syncope) could not be definitively determined. Clinical lessons include: recognising that hyponatraemia can manifest with behavioural disturbance and gait disturbance; implementing earlier falls assessment in patients with altered mental status; and ensuring vigilant supervision remains undistracted. The coroner found no clear medical failures in care, though the care assistant briefly used her phone prior to the fall. Earlier psychiatric and neurological assessment may have been beneficial.
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Specialties
Error types
Drugs involved
Clinical conditions
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