Deceased
Ronald Reginald Slatter
Demographics
93y, male
Date of death
2022-07-22
Finding date
2023-08-02
Cause of death
Alzheimer's dementia (as recorded on MCCD); however, the death resulted from a fall causing fracture of neck of right femur with subsequent complications
AI-generated summary
Ronald Reginald Slatter, aged 93, died at Mersey Community Hospital on 22 July 2022, three weeks after sustaining a fractured neck of right femur from a fall on 1 July 2022. While the coroner found no issues with his clinical care, a critical administrative failure occurred: the Medical Certificate of Cause of Death listed only Alzheimer's dementia and completely omitted reference to the fall and fracture that directly contributed to his death. The death was not reported to the coroner as legally required, discovered only during internal review in late September 2022. The coroner emphasised that all hospital medical staff must familiarise themselves with Coroners Act 1995 reporting requirements for deaths resulting from accidents or injuries, regardless of patient age or comorbidities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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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…
87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…
Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …
84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…
An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…
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