Finding into death of Aileen Mary McLeish
Deceased
Aileen Mary McLeish
Demographics
54y, female
Date of death
2023-09-08
Finding date
2025-05-12
Cause of death
Pulmonary thromboembolism complicating left calf deep venous thrombosis in the setting of fronto-temporal dementia
AI-generated summary
54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was found on the floor at 5:30 am by night shift staff. The care worker failed to follow her care plan (which required two-person assist for any movement), did not provide timely first aid, did not contact after-hours services for guidance, and left her on the floor for 30+ minutes before day shift arrived. The coroner found her care was not reasonable in her final moments. Clinical lessons include the critical importance of adhering to individualised care plans, recognising immobility as a VTE risk factor in vulnerable populations, and ensuring appropriate escalation and first aid response to falls, particularly in clients with complex needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Fall at night
- Prolonged immobility on floor following fall
- Failure to follow individualised care plan
- Delay in appropriate first aid response
- Failure to contact after-hours services for guidance
- Inadequate incident reporting
- Fronto-temporal dementia with progressive mobility decline
- Parkinson's disease affecting gait and mobility
Coroner's recommendations
- Claro Aged Care and Disability Services to ensure continued implementation of improved systems and safeguards at Wollert House
- Providers to ensure staff compliance with individualised care plans and care protocols for high-risk falls clients
- Providers to ensure appropriate escalation procedures and after-hours guidance systems are in place and followed
Full text
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