Coroner's Finding: Webberley, Patricia
Deceased
Patricia Mary Webberley
Demographics
87y, female
Date of death
2021-11-12
Finding date
2024-09-27
Cause of death
pneumonia following complications from a fractured left wrist sustained in a fall
AI-generated summary
Mrs Webberley, 87, resident of a residential aged care facility (RACF), sustained an unwitnessed fall on 1 November 2021 resulting in a left wrist fracture (Colles' fracture). She was initially assessed at the RACF but not transferred to hospital until the following day after geriatrician review. During hospital admission, she experienced a significant rectal bleed (500ml). The fracture and bleed were managed conservatively with family agreement for comfort care. She was discharged back to the RACF on 5 November 2021, deteriorated rapidly, and died of pneumonia on 12 November 2021. The coronial medical consultant found medical care was appropriate. However, the nursing consultant identified systemic issues at the RACF including inadequate falls risk documentation, insufficient hourly checks on night shift (2+ hours between checks versus required hourly), inadequate daytime rounding despite peak fall times being 4-8pm, and low overnight staffing ratios (1:24). The RACF subsequently implemented comprehensive improvements in clinical supervision, documentation, falls prevention strategies, and staffing.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- unwitnessed fall in bathroom at aged care facility
- left wrist fracture (Colles' fracture with comminution)
- rectal bleeding (500ml) after fracture reduction, secondary to severe diverticulosis
- advanced vascular dementia with delirium
- depression following spouse's death
- poor mobility and multiple previous falls
- inadequate falls risk assessment and documentation at RACF
- insufficient hourly checks on night shift at RACF
- low overnight staffing ratio (1:24)
- lack of daytime rounding despite peak fall times
Coroner's recommendations
- No formal recommendations issued by coroner; RACF responded comprehensively to identified systemic issues with improvements in clinical supervision, staffing levels, documentation systems, falls prevention programs, and governance structures implemented between 2022-2024
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