Finding into death of Sylvia Valerie Woolford
Deceased
Sylvia Valerie Woolford
Demographics
88y, female
Coroner
Coroner Audrey Jamieson
Date of death
2018-07-12
Finding date
2020-11-05
Cause of death
Complications of fractured neck of femur
AI-generated summary
An 88-year-old woman with advanced dementia died from complications following a fractured neck of femur sustained in a fall caused by another resident with vascular dementia in a secured aged care unit. The fall occurred on 3 June 2018, surgery was performed on 4 June, and the patient deteriorated over 6 weeks before dying on 12 July 2018. Clinical lessons include: adequate supervision and monitoring of aggressive residents is essential in locked dementia units; early recognition of assault-related injuries and their complications in elderly people post-operatively is critical; and systemic issues in aged care require full disclosure and cooperation with authorities. The coroner found the facility's risk management response appropriate but criticised initial non-disclosure of the assaulting resident's identity.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Fall caused by another resident with aggressive behaviour
- Advanced dementia in a Memory Support Unit
- Inadequate supervision or monitoring to prevent assault
- Elderly patient status with multiple comorbidities
- Post-operative complications following hip surgery
- Systemic atherosclerosis and multiple chronic conditions
Coroner's recommendations
- This Finding will be distributed widely to the Aged Care Quality and Safety Commission and the Royal Commission into Aged Care Quality and Safety
- Aged care facilities must cooperate fully with requests and facilitate full and frank disclosure when risks are identified
- Regulatory bodies must continue to collate, review and publish data on allegations of assault in aged care to provide accurate insight into issues requiring attention
- Enhanced monitoring and supervision protocols for residents with history of aggressive behaviour in secured units
Full text
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