Deceased
ENA EDITH VICKERS
Demographics
76y, female
Date of death
2012-08-04
Finding date
2016-02-25
Cause of death
Complications of head and neck injuries sustained in a fall
AI-generated summary
Mrs Ena Vickers, 76, with dementia and Parkinson's disease, suffered an unwitnessed fall at Embracia nursing home on 30 July 2012, sustaining head and neck injuries including acute subdural haematoma. The initial assessment by an Enrolled Nurse (Ms Della Gatta) was inadequate and did not escalate to medical attention appropriately. No Division 1 Registered Nurse was on-site until evening shift, limiting assessment capability. A call was made to the attending general practitioner whose advice not to transfer was reasonable based on information conveyed, but the coroner found the initial assessment deficient. The lack of a registered nurse assessment, failure to escalate despite significant head injury in a patient on aspirin, poor continuity of monitoring, and absence of post-incident review were key failures. Although early hospital transfer may not have changed outcome, it could have prevented distress experienced later.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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