Coroner's Finding: Taylor, Irene Barbara
Deceased
Irene Barbara Taylor
Demographics
99y, female
Date of death
2022-07-14
Finding date
2023-04-14
Cause of death
pneumonia due to a fractured right neck of femur (hip) sustained in a fall
AI-generated summary
A 99-year-old woman with advanced dementia resident in aged care fell and sustained a right femoral neck fracture. Despite being assessed as high falls risk with multiple prevention measures in place, she was not wearing hip protectors at the time of the fall. She developed pneumonia and died two days later. The coroner found no issues with falls risk assessment or most prevention measures, but identified that hip protectors were unavailable or soiled. Hip protectors may have prevented or reduced injury severity. The key clinical lesson is ensuring high-risk residents have appropriate protective equipment available and accessible at all times, not just prescribed but physically present and in use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- advanced dementia with cognitive decline
- impulsivity related to dementia
- high falls risk
- unavailability of hip protectors at time of fall
- hip protectors not worn despite being indicated
Coroner's recommendations
- Fairway Rise nursing home should take appropriate action to ensure that residents assessed as requiring hip protectors are fitted with them at all times when required
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