Finding into death of Jane Nola Rolph
Deceased
Jane Nola Rolph
Demographics
90y, female
Date of death
2018-10-07
Finding date
2020-05-04
Cause of death
Complications of a right fractured neck of femur (operated) sustained in a fall in a woman with dementia
AI-generated summary
A 90-year-old woman with dementia sustained a fractured neck of femur after being nudged by another aggressive dementia-affected resident in an aged care facility, resulting in a fall. Despite appropriate initial management, post-operative recovery, and return to the facility, her health deteriorated and she died in palliative care two weeks post-operatively. The coroner found the facility responded appropriately to the incident and implemented appropriate preventive strategies. However, the finding highlights that resident-to-resident aggression in aged care requires proactive rather than reactive management, and endorses published recommendations for preventing such injuries.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Procedures
Contributing factors
- resident-to-resident aggression by another dementia-affected resident
- dementia diagnosis
- advanced age
- previous falls at facility
- lack of witnesses to fall
Coroner's recommendations
- Support implementation of ten recommendations outlined in 'Recommendations for Prevention of Injury-Related Deaths in Residential Aged Care Services' by Professor Joseph Ibrahim and the Health Law & Ageing Research Unit, Monash University, particularly those focused on resident-to-resident aggression prevention
- Aged care facilities should address resident-to-resident aggression proactively rather than reactively
- Continued focus on improving public health and safety and preventing deaths from resident-to-resident aggression in residential aged care services
Full text
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