Finding into death of Leslie Frederick Alexander
Deceased
Leslie Frederick Alexander
Demographics
77y, male
Date of death
2015-04-01
Finding date
2016-02-08
Cause of death
Subarachnoid and subdural haemorrhage post head trauma secondary to a fall
AI-generated summary
Leslie Alexander, 77, died from subarachnoid and subdural haemorrhage following a fall at an aged care facility. He fell on 29 March and again on 30 March 2015, striking his head. Initial assessment by a locum GP found no head injury evidence and neurological observations were ceased. On 30 March morning, Mr Alexander deteriorated with confusion, drowsiness, and inability to follow commands. He was transferred to hospital where CT imaging revealed acute intracranial haemorrhage. Palliative care was instituted given his advanced age, comorbidities, and poor prognosis. The coroner found nursing documentation was suboptimal with poor chronology, missing entries, and retrospective notes. While neurological observation protocols were followed and appropriate escalation occurred once decline was apparent, clearer documentation might have identified deterioration earlier.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- High falls risk inadequately managed despite documented risk
- Head injury on 29 March assessed by locum GP without imaging despite mechanism of injury
- Neurological observations ceased after initial negative assessment
- Suboptimal nursing documentation with poor chronology and missing entries
- Delayed recognition of deterioration on morning of 30 March
- Cumulative falls (10 falls between November 2014 and March 2015)
Coroner's recommendations
- Opal Gracedale conduct training to ensure staff understand the importance of clear and consistent documentation in client and medical records
Full text
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