Coroner's Finding: de-identified OQ -2
Deceased
OQ
Demographics
84y, male
Date of death
2024-06-28
Finding date
2025-06-13
Cause of death
Head injury - left lateral convexity acute subdural haematoma with 2mm midline shift right, sustained in a fall in the Rehabilitation Unit
AI-generated summary
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 acute hospital, but this critical need was not communicated during transfer. Without sitter supervision, he fell and sustained a fatal acute subdural haematoma. The coroner found the handover information inadequate and stated that if a sitter had been present, the fall would likely not have occurred. Key lessons: ensure comprehensive handover of all falls prevention measures including supervision requirements; delay rehabilitation admission if cognitive status unclear; use bed/chair alarms; allocate appropriate rooms for high-risk patients; strengthen inter-unit communication protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to communicate need for patient sitter during handover between acute hospital and rehabilitation unit
- Inadequate handover information regarding falls prevention measures
- Inadequate assessment of cognitive status prior to rehabilitation admission
- High falls risk not appropriately mitigated at rehabilitation unit
- Patient allocated to non-ideal room for high falls risk patients
- Parkinson's disease
- Moderate dementia
- Atrial flutter
- Covid-19 infection
Coroner's recommendations
- Calvary to add an alert to its electronic systems regarding patients who require patient supervisors so that this critical information is communicated as handover information between nursing shifts and upon transfer of care to another clinical area
- Calvary to revise the Rehabilitation Pre-Admission Assessment Screening Tool to include a specific question regarding whether the patient is currently under supervision by a patient supervisor and the results of any recent cognitive assessment
- Patients who currently require a patient supervisor to be excluded from participation in the dedicated rehabilitation program
- Calvary to continue to review at appropriate intervals its processes for assessing the need of a patient for a patient supervisor
- Calvary to review the efficacy of procedures and communication at handover times relating to a patient's requirement for a supervisor
- Calvary to implement other related recommendations from its Serious Clinical Incident Investigation relating to this case
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