Deceased
Aubrey Charles Reeve
Demographics
98y, male
Date of death
2023-07-28
Finding date
2023-12-18
Cause of death
comminuted pertrochanteric fracture of left hip sustained in mechanical fall
AI-generated summary
A 98-year-old man with osteoporosis, dementia, and ischaemic heart disease sustained a comminuted pertrochanteric hip fracture in a fall at his residential aged care facility on 24 July 2023, dying four days later. He had experienced escalating falls in the prior year. The coroner found the care substandard, identifying critical failures: movement detectors in his room were non-functional despite being fitted, preventing detection of mobilisation that might have allowed staff assistance; documentation was inadequate with no progress notes, falls assessment, or care plans provided; and the timing of last observation and overnight checks remained unclear. While the hospital's decision to palliate rather than surgically intervene was appropriate, the preventable fall resulted from inadequate safety monitoring and assessment in a high-risk resident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
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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