Coronial
VICaged care

Finding into death of Maria Grazia Nardiello

Deceased

Maria Grazia Nardiello

Demographics

90y, female

Coroner

Coroner Simon McGregor

Date of death

2022-02-23

Finding date

2025-03-14

Cause of death

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.

Specialties

geriatric medicineorthopaedic surgerypalliative carepsychiatry

Error types

system

Clinical conditions

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

  1. Implementation of more rigorous pre-admission screening and assessment
  2. Earlier referral to Dementia Support Australia
  3. More regular and detailed case conferencing regarding difficult behavioural issues
  4. Development of occupational violence working party
  5. Installation of CCTV
  6. Enhanced staff training
  7. 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
Full text

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