Finding into death of Josephine Helen Clarke
Deceased
Josephine Helen Clarke
Demographics
69y, female
Coroner
Deputy State Coroner Caitlin English
Date of death
2018-09-11
Finding date
2021-04-23
Cause of death
Complications of a subdural haemorrhage (palliated) sustained in a fall
AI-generated summary
Josephine Helen Clarke, age 69, died from complications of a subdural haemorrhage sustained in a fall at Kingston Centre rehabilitation facility on 11 September 2018. Mrs Clarke had been recovering from a subarachnoid haemorrhage and aneurysm repair in June 2018 and was assessed as high falls risk requiring 'constant supervision'. On the day of death, she was transferred to a commode chair in the toilet and subsequently found on the floor after an unwitnessed fall. The critical clinical lesson involves ambiguity in falls prevention policies: 'constant supervision' was not documented on her falls prevention form despite her high-risk status (score 23, high being >17). Nursing staff checked on her twice during toileting, but she was left unattended. The coroner identified this as a missed prevention opportunity despite acceptable nursing practice standards. Key issues included: unclear definition of 'constant supervision' in busy ward environments, Mrs Clarke's fluctuating cognition (previously documented as confused/disoriented) being inconsistently described, and lack of clarity regarding whether her cognitive impairment necessitated more intensive supervision than provided. Recommendations focused on clarifying ambiguous falls prevention terminology and ensuring cognitive status directly informs individual intervention strategies.
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Specialties
Error types
Clinical conditions
Contributing factors
- unwitnessed fall from commode chair while toileting
- patient left unattended despite high falls risk classification
- ambiguous 'constant supervision' requirement not documented on falls prevention form
- fluctuating cognition and confusion not consistently reflected in risk assessment documentation
- lack of clarity regarding practical implementation of falls prevention strategies in busy multi-bay ward environment
- patient's previous falls from seated position requiring propping to prevent collapse
Coroner's recommendations
- Monash Health review its falls related guidelines and other supporting documents to clarify ambiguous terms or instructions including, but not limited to, 'constant supervision' and 'N/A'
- Monash Health review its falls related guidelines and other supporting documents so that a patient's cognitive issues are more clearly identified and documented in order to inform the individual risk mitigation and intervention strategies to be put in place
- Monash Health review how the application and implementation of falls prevention mitigation and intervention strategies are recorded for individual patients with a view to providing consistent care
- Monash Health review how consumers and their families are informed of falls prevention mitigation strategies and interventions with a view to reducing ambiguity
Full text
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