Deceased
Eileen Violet Smith
Demographics
88y, female
Coroner
Coroner Leveasque Peterson
Date of death
2019-09-13
Finding date
2021-11-30
Cause of death
Head injury in a fall due to atrial fibrillation on anti-coagulants
AI-generated summary
An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a documented falls management plan requiring two-person assistance. The fall occurred because staff were implementing individualized risk assessments rather than following established care plans. Key clinical lessons include: strict adherence to documented falls prevention protocols is essential in high-risk patients; nursing students require explicit education on falls management and supervision frameworks; and inconsistent practice by senior staff undermines patient safety protocols. The hospital had appropriate policies but implementation was suboptimal. Early recognition of the subdural haemorrhage and appropriate consultation with neurosurgery occurred, but the initial preventable fall was the critical event.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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