Finding into death of Heather Amy Robertson
Deceased
Heather Amy Robertson
Demographics
83y, female
Date of death
2022-07-28
Finding date
2023-01-16
Cause of death
Complications arising from a fall with C2 fracture and neck of femur fracture
AI-generated summary
An 83-year-old woman with dementia, Alzheimer's disease, and a prior hip fracture sustained injuries from a fall in her aged care facility's dining room. Staff were absent from the dining room for approximately 7 minutes during mealtimes, contrary to facility policy requiring continuous supervision. The resident stood and walked unobserved to an adjoining lounge area where she lost balance and fell, sustaining a C2 vertebral fracture and neck of femur fracture. She died 5 days later from complications of these injuries. The coroner found inadequate supervision was the critical failure. Clinical lessons include: dementia patients require continuous, attentive supervision during mealtimes; prior fall incidents should trigger enhanced monitoring; staffing must be sufficient to maintain policy compliance; and documented risks of independent ambulation necessitate constant observation to prevent preventable injuries in vulnerable aged populations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inadequate supervision of resident during mealtimes
- Staff absence from dining room for approximately 7 minutes
- Breach of facility catering policy requiring continuous staff presence
- Dementia and cognitive impairment limiting resident's judgment
- Prior fall history and documented need for close supervision
- Resident able to ambulate unassisted despite documented requirement for assistance
Coroner's recommendations
- Trinity Manor should review its staffing arrangements in its dining rooms to ensure that there is adequate supervision of residents during mealtimes
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