Deceased
PATRICIA MARY COOK
Demographics
85y, female
Date of death
2007-10-05
Finding date
2010-08-28
Cause of death
Complications of subdural haematoma (evacuated), secondary to fall, contributed to by warfarin therapy for atrial fibrillation
AI-generated summary
Patricia Cook, 85, died from complications of a subdural haematoma following a fall at a supported residential service (SRS) while on warfarin for atrial fibrillation. She fell on 30 September 2007, striking her head. Personal care attendants (PCAs) with minimal training assessed her as having no apparent injury and did not call a doctor or ambulance, allowing 4 hours to elapse before she collapsed. The facility's Falls Policy was ambiguous and permitted staff discretion not to notify doctors if residents appeared well, reflecting inadequate staff training in head injury recognition, especially in anticoagulated patients. While earlier medical assessment would likely have improved prognosis, the coroner could not establish with certainty that earlier intervention would have prevented death, given documented delays in locum doctor availability. The case highlights systemic failures: lack of prescriptive falls protocols in unregulated residential facilities, absence of medically trained staff, and inadequate staff education. Post-death, the facility implemented substantial policy and training improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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