Coroner's Finding: Chapman, Jane Ann
Deceased
Jane Ann Chapman
Demographics
74y, female
Date of death
2022-07-04
Finding date
2024-09-12
Cause of death
Post-operative exacerbation of delirium and terminal functional deterioration due to right hip hemiarthroplasty following a right neck of femur fracture due to a fall from bed in hospital
AI-generated summary
Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-operatively, she developed diabetic ketoacidosis and influenza A, requiring ICU admission. She died from post-operative delirium and functional deterioration. The fall was preventable: the coroner found that failure to raise bed rails and leave her unsupervised were key factors. Contributing system issues included bed blockage, staffing shortages limiting supervision, and unavailable Hi-Lo beds. The coroner emphasised that awareness of her high falls risk should have prompted closer attention to basic safety measures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- fall from bed in Emergency Department
- failure to raise bed rails
- inadequate supervision of high-risk patient
- hospital bed blockage and access block
- staffing shortages
- unavailable Hi-Lo adjustable beds
- delirium
- influenza A
- diabetes mellitus
- post-operative complications
Coroner's recommendations
- North West Regional Hospital should re-visit the RCA recommendations and consider whether there is current need to reinforce those recommendations and/or take additional safety measures to prevent falls in the Emergency Department
- Place patients with delirium or cognitive impairment in high visibility Emergency Department areas or utilise a patient sitter
- Source additional Hi-Lo adjustable beds to accommodate patients in the Emergency Department with delirium or cognitive impairment
- Provide directions to staff for familiarisation with bed rail usage in the Emergency Department
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