Coronial
VICaged care

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

geriatric medicineorthopaedic surgerypalliative caregeneral practice

Error types

system

Clinical conditions

fractured neck of femurAlzheimer's diseasedementiaosteoporosisosteoarthrosishypertensionhypothyroidismrenal failuresystemic atherosclerosiscerebral atrophyvascular dementia

Procedures

hemiarthroplasty

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

  1. This Finding will be distributed widely to the Aged Care Quality and Safety Commission and the Royal Commission into Aged Care Quality and Safety
  2. Aged care facilities must cooperate fully with requests and facilitate full and frank disclosure when risks are identified
  3. 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
  4. Enhanced monitoring and supervision protocols for residents with history of aggressive behaviour in secured units
Full text

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