Deceased
Allan Roy Bird
Demographics
92y, male
Date of death
2024-08-22
Finding date
2026-01-07
Cause of death
Consequences of accidental fall at RACF: post-operative delirium, left femoral intramedullary nail insertion, and left neck of femur intertrochanteric fracture; contributed to by age-related frailty, coronary artery disease, hypothyroidism, and atrial fibrillation
AI-generated summary
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner identified missed opportunities in falls risk assessment and prevention. Mr Bird was assessed as low falls risk despite being 92 years old, taking three medications including a benzodiazepine that increase fall risk, having documented impulsivity regarding mobility, and lacking a comprehensive care plan following transition to permanent residency. No formalised falls prevention strategies were clearly documented. Enhanced supervision, bed sensors, and hip protectors should have been considered. The coroner acknowledged the patient's tendency to mobilise without assistance may have led to a fall regardless, but proper risk recognition and mitigation could have prevented or reduced injury severity.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
93y · Female·acute right lower limb ischaemia
Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite parace…
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