Finding into death of Patricia O'Connor
Deceased
Patricia O'Connor
Demographics
84y, female
Coroner
Coroner Simon McGregor
Date of death
2017-09-07
Finding date
2019-10-15
Cause of death
Multisystem organ failure related to complications from a fall resulting in hip fracture (operated)
AI-generated summary
Patricia O'Connor, 84-year-old woman with bipolar disorder, was admitted involuntarily to Sunshine Aged Persons Mental Health Unit on 15 August 2017 during a manic relapse. On 25 August, she fell and fractured her right femur while ambulating with a frame in the low-stimulus area despite being assessed as high falls risk. She underwent surgery on 27 August but her acute mania, severe agitation, and challenging behaviour made post-operative management extremely difficult. Staff could not administer necessary blood transfusion due to inability to obtain vascular access from her agitated state. She deteriorated with post-operative complications and died 7 September 2017 from multisystem organ failure. The coroner found care appropriate given the challenging circumstances, though noted Western Health's processes were not fully complied with as she wasn't transferred to an orthopaedic ward due to bed unavailability.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Fall resulting in right femoral fracture
- Post-operative complications including anaemia
- Inability to obtain vascular access for blood transfusion due to patient agitation
- Severe acute mania and agitation impairing post-operative management
- Delirium exacerbated by pain
- Non-compliance with medication and nursing interventions prior to admission
- Frequent wandering and intrusive behaviours increasing fall risk
- Unavailability of orthopaedic bed delaying appropriate transfer
Full text
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