Finding into death of Jean Meyer
Deceased
Jean Meyer
Demographics
96y, female
Date of death
2023-06-20
Finding date
2024-04-30
Cause of death
complications following a fractured distal right femur
AI-generated summary
A 96-year-old woman died from complications of a hip fracture sustained when pushed by a fellow resident with severe dementia at an aged care facility. The resident pressed the call bell for help, but the system was non-functional due to technical faults that day. While 15-minute manual rounding was implemented as an alternative, the coroner found this reasonable in the circumstances. The death was not preventable through call bell repair, as the altercation likely would have occurred regardless. The coroner emphasised the ongoing challenge of resident-to-resident aggression in aged care and the need for improved risk monitoring, assessment, and management processes to prevent future incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- fall caused by resident-to-resident aggression
- fellow resident with severe dementia who was not adequately supervised
- call bell system malfunction on the day of the incident
- post-operative aspiration pneumonia
- poor pre-morbid health and mobility
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