Coroner's Finding: Kerrie Dawn Grant

Contributing factors

• recurrent falls with inability to self-recover from floor
• inadequate discharge planning and multidisciplinary coordination
• medical alert pendant not collected or available at discharge
• community support services not operational due to Easter holiday timing
• no pre-discharge occupational therapy review completed
• discharge occurring over public holiday period when services unavailable
• failure to directly liaise with general practitioner prior to discharge
• assessment of home service needs deferred to general practitioner post-discharge
• absence of unified falls risk assessment tool
• inadequate consideration of alternative living arrangements such as rehabilitation or residential care
• prolonged immobility on floor causing skin breakdown and potential infection
• social isolation with no local family or social supports
• deconditioning from lengthy hospitalization

Coroner's recommendations

1. Implementation of a single validated falls risk assessment tool with appropriate falls prevention strategies and interventions for varied levels of falls risk to be used by all clinicians
2. Review of discharge planning practices, especially around holiday periods, where at-risk individuals may be discharged without appropriate access to supportive services
3. Discharge planning for persons at high risk of falls and returning to independent living to include direct liaison with their community general practitioner prior to discharge to ensure appropriate supports, appointments and referrals are in place
4. Implementation of an alerts system for barriers to discharge which requires resolution or mitigation of each alert prior to discharge