Deceased
John Frederick Reimers
Demographics
63y, male
Coroner
Coroner Audrey Jamieson
Date of death
2016-12-17
Finding date
2019-08-23
Cause of death
complications of an inverted positional event (asphyxia from airway occlusion)
AI-generated summary
A 63-year-old man with previous stroke and left-sided paralysis fell headfirst into his bedside drawer while attempting to open it from his motorised wheelchair. He became trapped with his airway occluded. An enrolled nurse and personal care assistant were unable to remove him safely and called emergency services at 05.10 hours. Due to use of Protocol 17 (fall) rather than Protocol 22 (entrapment), the ambulance dispatch was delayed. Paramedics arrived at 05.42 hours and found him unresponsive and cyanosed, already deceased. CPR was commenced briefly but discontinued when a Not-For-Resuscitation directive was located. The coroner found the death preventable due to: inadequate on-site registered nurse staffing; failure of the enrolled nurse to take vital signs, remove the patient, or contact the on-call RN; poor emergency dispatch protocol selection; and ambiguous advance care planning documentation. The case highlights critical systemic failures in aged care staffing, training, clinical assessment, and communication during emergencies.
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
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A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
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