Coronial
TAShospital

Coroner's Finding: de-identified KW

Demographics

87y, female

Date of death

2023-12-25

Finding date

2026-01-21

Cause of death

right thigh haematoma as a consequence of a periprosthetic fracture of the right distal femur caused by several falls at home

AI-generated summary

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 rehabilitation at a district hospital, developing severe malnutrition over 4-5 weeks with 7.1kg weight loss despite documented swallowing difficulties (Zenker's diverticulum). No definitive nutritional support plan was implemented early. She developed a spontaneous thigh haematoma in her malnourished state and died from bleeding complications. The coroner found malnutrition was a contributing factor. Key lessons: earlier recognition that rehabilitation was unrealistic; timely transfer back to tertiary hospital for enteral nutrition; earlier goals-of-care discussions; and improved nutritional assessment protocols at district hospital level.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

orthopaedic surgerygeriatric medicinerehabilitation medicinedieteticsemergency medicine

Error types

diagnosticsystemdelay

Clinical conditions

periprosthetic fracturemalnutritionzenker's diverticulumdysphagiahospital-acquired malnutritionanaemiadeliriumatrial fibrillationdiabetes mellitusperipheral vascular diseasehaematoma

Procedures

distal femur replacement surgery

Contributing factors

  • malnutrition and significant weight loss
  • failure to implement definitive nutritional support plan early
  • swallowing difficulties due to Zenker's diverticulum
  • advanced age
  • multiple comorbidities including cardiac conditions and diabetes
  • patient refusal of rehabilitation and assistance
  • prolonged trauma and surgery
  • poor prognosis following fracture and surgery

Coroner's recommendations

  1. The Tasmanian Health Service should review the adequacy of existing policies and guidelines regarding the care and treatment of rehabilitation patients at the New Norfolk District Hospital, specifically pertaining to: ongoing assessment of the suitability of patients for rehabilitation; the scope of treatment measures available to rehabilitation patients; and the circumstances under which rehabilitation patients should be transferred to the RHH for further or different treatment
  2. Following such review, the Tasmanian Health Service should implement necessary changes to existing policies and guidelines, together with a strategy for staff education
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