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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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