Deceased
Ross Stuart Blades
Demographics
71y, male
Date of death
2024-05-21
Finding date
2024-11-01
Cause of death
RACF acquired pneumonia and Alzheimer dementia
AI-generated summary
Ross Stuart Blades, a 71-year-old man with Alzheimer dementia and squamous cell carcinoma, died of RACF-acquired pneumonia while residing in an aged care facility. He was found deceased on the floor beside his bed. The coroner found death resulted from natural causes. However, the Root Cause Analysis identified significant deficiencies in falls assessment, falls prevention, wound care documentation, and management of his sacral pressure injury. While the pressure injury was a contributing factor to death, the coroner found insufficient evidence that neglect of the wound contributed to his death, noting such injuries can progress rapidly despite optimal care. The coroner recommended the RACF review and improve its policies and practices for wound care, wound management, and documentation at regular intervals.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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…
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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