Coroner's Finding: de-identified OQ -2

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

1. 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
2. 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
3. Patients who currently require a patient supervisor to be excluded from participation in the dedicated rehabilitation program
4. Calvary to continue to review at appropriate intervals its processes for assessing the need of a patient for a patient supervisor
5. Calvary to review the efficacy of procedures and communication at handover times relating to a patient's requirement for a supervisor
6. Calvary to implement other related recommendations from its Serious Clinical Incident Investigation relating to this case