Coroner's Finding: Lowe, Wayne Anthony
Deceased
Wayne Anthony Lowe
Demographics
58y, male
Date of death
2023-02-20
Finding date
2025-01-20
Cause of death
multiorgan failure due to sepsis resulting from repeatedly fractured left humerus
AI-generated summary
Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged against medical advice prematurely, then re-admitted after re-fracturing the same arm. During his hospital stay, he suffered a third fall on 3 February 2023 injuring his left humerus. Clinical lessons: falls risk assessment should occur at admission, not after the first fall. Delirium assessment was inadequate and was a significant contributing factor. A Patient Safety Assistant was unavailable at the time of the preventable fall. While his death could not ultimately have been prevented given his poor baseline state, the fall hastened his decline. The coroner commended the health service for implementing improved falls risk screening tools and prevention strategies hospital-wide.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- delayed falls risk assessment (not completed until after first fall)
- inadequate delirium and cognitive impairment assessment
- unavailability of Patient Safety Assistant at time of preventable fall on 3 February 2023
- pre-existing poor physical state including alcohol dependency, mental health issues, diabetes, pancreatic insufficiency
- premature discharge against medical advice after initial surgery
- hospital-acquired pneumonia
- acute kidney injury
- liver failure
Coroner's recommendations
- Falls risk assessments and prevention strategies should be implemented upon hospital admission, not after the first fall
- Delirium and cognitive impairment risk screening should be systematically undertaken
- Patient Safety Assistant attendance should be documented and maintained as recommended
- Communication with patient's family regarding risks should be improved
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