Coroner's Finding: Tweedie, Valma Ann
Deceased
Valma Ann Tweedie
Demographics
72y, female
Date of death
2021-08-22
Finding date
2023
Cause of death
Pneumonia following cervical spine injuries sustained in an unwitnessed mechanical fall from standing
AI-generated summary
Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable dementia. While in hospital, there was a delayed identification of her C4-C6 spinal injury (approximately two weeks), caused by deviations from protocols and incomplete neurological observations. The Root Cause Analysis identified multiple systems failures including inadequate neurological assessment at presentation, lack of clinical support for observation criteria, and failure to escalate abnormal findings. Critically, Ms Tweedie was left unsupervised outside in darkness and rain at 3:10 am by a single support worker, who did not verify her safe return inside. This negligent supervision directly led to the fatal fall. The underlying cause was St Michael's Association's failure to conduct substantive care reviews after she turned 65, particularly given documented concerns about dementia and fall risk.
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Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Unsupervised client left alone outside in darkness and rain in early morning
- Single support worker unable to provide adequate supervision of three clients
- Failure to verify safe return of client to inside facility
- Delayed identification of C4-C6 cervical spine injury (approximately two weeks)
- Incomplete neurological observations in Emergency Department
- Lack of clinical support and protocols for neurological assessment
- Failure to escalate abnormal neurological observations
- Inadequate care planning despite known fall history and mobility problems
- No substantive multidisciplinary care review after client's 65th birthday
- Lack of response to GP concerns about possible dementia
- Pre-existing spinal degeneration predisposing to central cord syndrome
- Long-term smoking history increasing pneumonia risk
- Spinal injury causing possible diaphragmatic paralysis, predisposing to collapsed lung
- Confusion and inconsistency in support worker's account of events
Coroner's recommendations
- The Tasmanian Health Service implement the recommendations contained in the Root Cause Analysis report (dated 21 December 2021) within the completion dates set out in that report
- St Michael's Association Inc. undertake a review with respect to its risk identification and management systems relating to residents at increased risk of falls
Full text
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