Coroner's Finding: Jones, Emily Margaret Rose
Deceased
Emily Margaret Rose Jones
Demographics
82y, female
Date of death
2021-11-15
Finding date
2023-10-11
Cause of death
traumatic closed head injury (subdural haematoma) resulting from a fall from standing
AI-generated summary
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated for atrial fibrillation with metoprolol and flecainide. At RHH, both aspirin and apixaban were prescribed due to medication documentation issues—aspirin appeared in the Webster pack but not in the consultant's discharge letter, which was misfiled. The combination of anticoagulants increased bleeding risk. Metoprolol and flecainide also contributed to symptomatic bradycardia and cognitive decline, though her cognition was improving at the time of the fall. Key clinical lessons: ensure direct communication between hospitals when patients are readmitted shortly after discharge; verify discharge medication lists carefully; conduct complete pharmacy reviews despite staffing constraints; and file specialist correspondence in accessible locations. Falls prevention strategies were appropriate, though reassessment after acute arrhythmia on 13 November was not undertaken.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- unwitnessed fall in hospital setting
- high falls risk due to delirium and cognitive disorder
- dual anticoagulation (aspirin and apixaban) increasing bleeding risk
- medication documentation and filing errors at RHH
- symptomatic bradycardia induced by metoprolol and flecainide
- cognitive decline secondary to bradycardia and medication effects
- lack of communication between Hobart Private Hospital and Royal Hobart Hospital
- delayed receipt and misfiling of discharge letter from cardiologist
- incomplete pharmacy medication review due to staffing issues
- atrial fibrillation with rapid ventricular rates requiring complex management
- chronic kidney disease affecting drug clearance
- delayed cardiology review over the weekend
Coroner's recommendations
- It would be prudent in cases where a patient is admitted to RHH soon after discharge from another hospital that the treating staff at RHH should contact the doctor at the other hospital under whose care the patient was admitted, as that doctor could provide invaluable advice and avoid difficulties caused by delays in transmission or misfiling of discharge information
- Improve the process for transfer of clinical information from external organisations, including standardised filing of specialist correspondence in easily accessible locations
- Complete pharmacy medication reviews should be prioritised despite staffing constraints to identify drug interactions such as dual anticoagulation
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