Coroner's Finding: Vieth, Karl Heinz

Contributing factors

• prolonged inappropriate admission to Emergency Medical Unit (EMU) unsuitable for complex multi-night stays
• failure to prioritise timely transfer to appropriate inpatient medical ward
• lack of clear bed allocation guidelines and patient prioritisation processes
• absence of direct supervision by treating medical teams in EMU
• development of delirium and confusion during EMU admission
• hospital access block and bed capacity constraints
• underground location of EMU without natural light contributing to delirium
• failure to arrange physiotherapy and occupational therapy assessment for high falls risk patient
• inadequate visibility of patient bed location in EMU

Coroner's recommendations

1. Investigate implementation of structured geriatric assessment programmes such as Geriatric Emergency Department Intervention (GEDI) or similar internationally validated models to improve identification, prioritisation, and management of elderly and high-risk patients
2. Establish clear, transparent decision-making guidelines and processes for emergency department admissions and bed allocation prioritisation, with consistent application across all staff
3. Implement organisational approach to elderly care coordination addressing delirium, falls, and functional decline through programmes such as 'End PJ Paralysis', 'Eat Walk Engage', or 'Move it or Lose it'
4. Develop facility-wide prioritisation criteria to identify vulnerable patients and ensure 'right patient, right location, right staff, right equipment' placement
5. Establish definitive timeframes with audit mechanisms for implementing identified safety improvements from root cause analyses
6. Implement multifactorial falls prevention strategies including baseline mobility assessments, delirium management, medication review, vision assessment, environmental hazard reduction, appropriate equipment, regular visual checks, and line-of-sight bed allocation
7. Ensure high-risk patients have timely physiotherapy and occupational therapy assessment
8. Address access block and patient flow issues through improved resource allocation and facility management rather than 'outlier' patient placement in unsuitable environments
9. Conduct review of falling prevention quality improvement activities in ED with specific details of implementation and processes