Finding into death of Edna May Pullen
Deceased
Edna May Pullen
Demographics
93y, female
Date of death
2012-02-13
Finding date
2015-10-08
Cause of death
Subdural haemorrhage in the setting of a fall (palliated)
AI-generated summary
A 93-year-old woman with a history of falls was discharged from hospital following treatment for subdural haematoma from a prior fall. Discharge planning included a home assessment by occupational therapy, during which the patient successfully demonstrated entering her home using a four-wheeled frame despite concerns from her daughter about the entrance configuration. The assessment identified a tether for the front door as the only recommended modification. However, on returning home, the patient deviated from the demonstrated technique when entering independently. She fell backwards through the flywire door, striking her head, resulting in recurrent subdural haematoma. While the coroner found the entrance implicated in the accident, no breach of clinical care was identified. The coroner noted that holding the flywire door open mechanically or manually would likely have prevented the accident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Fall at home on discharge from hospital
- Flywire door implicated in the fall mechanism
- Deviation from demonstrated safe entry technique
- Patient used different manoeuvre on discharge day compared to successful method during home assessment
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