Coronial
VICaged care

Finding into death of Jane Nola Rolph

Deceased

Jane Nola Rolph

Demographics

90y, female

Coroner

Coroner Audrey Jamieson

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. Report an inaccuracy.

Specialties

geriatric medicineorthopaedic surgerypalliative careforensic medicine

Clinical conditions

dementiafractured neck of femurhypertensionhypokalaemiahyperlipidaemiatransient ischaemic attack

Procedures

hemiarthroplasty

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

  1. 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
  2. Aged care facilities should address resident-to-resident aggression proactively rather than reactively
  3. 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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