Finding into death of Nazlou (Helen) Danilidis
Deceased
Nazlou (Helen) Danilidis
Demographics
94y, female
Date of death
2024-06-25
Finding date
2025-05-21
Cause of death
Complications of a fractured neck of femur sustained in an unwitnessed in-hospital fall in the setting of valvular heart disease, pulmonary hypertension, chronic obstructive pulmonary disease, and atherosclerotic cardiovascular disease
AI-generated summary
A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of falls mitigation strategies including sensor mat alarms, hourly rounding, and bed positioning near the nurse's station, the patient walked to the toilet unattended and fell. The sensor mat failed to alarm despite later testing showing it was operational. Key clinical lessons: falls prevention requires integration of multiple strategies beyond electronic surveillance alone; adequate documentation of rounding and toileting assistance is essential; delirium assessment and cognitive impairment screening should guide fall risk interventions; minimising bed moves in confused elderly patients reduces disorientation; and sensor devices require proper placement testing before use. The coroner found falls management interventions inadequate and recommended review of sensor mat protocols and enhanced supervision strategies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inadequate falls management interventions
- Failure of sensor mat alarm to activate despite operational status
- Incomplete documentation of hourly rounding
- Lack of documented toileting assistance
- Confusion and disorientation from medications (lorazepam, oxycodone) and hypoxia
- Unfamiliar hospital environment
- Multiple bed moves during hospital stay (six moves) contributing to increased confusion
- Heavy reliance on electronic surveillance without adequate physical supervision
- Lack of formal delirium assessment
Coroner's recommendations
- Northern Health should review their relevant falls risk mitigation strategies including relevant policies and procedures
- Ensure that the use of any sensor mat alarms require not only proper placement and positioning but should be tested to ensure activation and alarms are operational before implementation with a patient
- Implement and document purposeful rounding on every shift
- Complete all risk screening assessments including delirium and cognitive impairment on EMR on every shift
- Where possible limit bed moves for patients over 65 with increased confusion, as this increases their risk of falls
- Highlight to nursing staff via huddles and email the importance of placing sensor mats according to manufacture guidelines
Full text
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