Surgical repair of fractured neck of femur sustained in a fall complicated by COVID-19 infection
AI-generated summary
Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dementia and aggressive behaviour, falling in a corridor. The fracture was successfully repaired surgically, but Maria developed hypoxia and reduced consciousness due to concurrent COVID-19 infection and died in palliative care. The coroner found no intent and commended the facility for subsequent improvements. The CPU identified that while the facility met standards for dementia care, there is a systemic gap in escalation pathways for managing acutely unmanageable resident behaviours in aged care settings, with no services able to provide timely intensive response when required.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
fractured neck of femurAlzheimer's diseasevascular dementiaosteoarthritisprevious strokeCOVID-19 infectionhypoxiabehaviours and psychological symptoms of dementia
Procedures
femoral nail insertion for neck of femur fracture
Contributing factors
Another resident's aggressive behaviour and physical push causing fall
COVID-19 infection acquired around time of fall
Age and pre-existing dementia
Osteoarthritis and previous stroke
Gap in escalation pathways for managing acute unmanageable resident behaviour in aged care
Continued wandering behaviour despite geriatrician assessment
Coroner's recommendations
Implementation of more rigorous pre-admission screening and assessment
Earlier referral to Dementia Support Australia
More regular and detailed case conferencing regarding difficult behavioural issues
Development of occupational violence working party
Installation of CCTV
Enhanced staff training
Broader investigation through Deputy State Coroner Spanos' cluster inquest into aged care resident aggression (nine cases, 2021) to explore systems supporting aged care homes in managing escalating behaviour
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