Coroner's Finding: Bird, Allan Roy
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.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Inadequate falls risk assessment
- Misclassification as low falls risk despite age 92
- Inadequate documentation of falls prevention strategies
- Medication-related fall risk (benzodiazepine and other medications)
- Lack of comprehensive care plan on transition to permanent residency
- Patient impulsivity regarding mobility without aid or assistance
- No functional decline reassessment before death
- Age-related frailty and sarcopenia
- Comorbid conditions: coronary artery disease, hypothyroidism, atrial fibrillation
Coroner's recommendations
- Falls risk assessments should properly consider advanced age (92 years) as a primary risk factor
- Medication reviews should identify benzodiazepines and other fall-risk increasing drugs as risk factors
- Comprehensive falls prevention strategies should be clearly documented for all high-risk residents
- Formal care plans should be implemented when patients transition from respite to permanent residency
- Functional decline should trigger reassessment of falls risk
- Enhanced supervision should be considered for high-risk residents
- Bed sensors should be offered to high-risk residents
- Hip protectors should be offered to high-risk residents
- The RACF's recommended measures for rigorous falls assessments and prevention strategies should be implemented without delay
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