Deceased
Moira McCarthy
Demographics
85y, female
Coroner
Coroner Gregory McNamara
Date of death
2013-05-05
Finding date
2013
Cause of death
Hypostatic bronchopneumonia complicating fractured occipital condyle and left neck of femur, secondary to a fall
AI-generated summary
Moira McCarthy, an 85-year-old woman with dementia and multiple comorbidities requiring high-level aged care nursing, sustained a fall on 24 April 2013 when a ceiling hoist descended unexpectedly during a patient transfer. She was struck on the head and fell to the ground, sustaining a fractured occipital condyle and left neck of femur. Despite conservative management of fractures, she developed aspirational pneumonia and died on 5 May 2013. Investigation determined the hoist was in safe working order. The most probable cause was operator error—the toggle switch remaining in de-installation mode rather than being switched to patient transfer mode before the up button was pressed. This allowed the hoist to descend while beeping. Clinical learning: proper equipment mode selection and confirmation before use is critical; staff must be trained to identify mode-specific auditory/visual cues and pause if unexpected sounds occur.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
80y · Female·multiple injuries in the setting of a fall
Catherine Mary Reid, aged 80, died from multiple fractures sustained in a fall during a mechanical hoist transfer at a disability care facility. While being transferred from wheelchair to bed using an overhead ceiling ho…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.