Coroner's Finding: Martin, Shirley Dorothy
Deceased
Shirley Dorothy Dawn Martin
Demographics
91y, female
Date of death
2022-08-24
Finding date
2024-12-18
Cause of death
exacerbation of behavioural and psychological symptoms of dementia following surgical repair of hip fracture
AI-generated summary
Shirley Dorothy Dawn Martin, an 91-year-old with advanced Alzheimer's disease and multiple comorbidities, sustained a hip fracture from an unwitnessed fall at an aged care facility on 8 August 2022. She underwent surgical repair on 9 August 2022 but post-operatively remained confused, agitated, and refused medications. She was discharged back to aged care on 19 August 2022 where her behavioural and psychological symptoms of dementia exacerbated significantly. She deteriorated rapidly and died five days later. The coroner found the RACF's falls prevention strategies, post-fall care, and response were appropriate and adequate. A 3-hour 47-minute ambulance delay was attributed to appropriate triage categorisation, regional surge conditions, and staffing shortages. The death was not preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- advanced Alzheimer's disease with progressive cognitive decline
- confusion and agitation in the weeks preceding the fall
- unwitnessed fall at aged care facility
- post-operative delirium and behavioural disturbance
- refusal of medications post-operatively
- minimal pain management in immediate post-operative period
- rapid deterioration following return to aged care
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