Finding into death of Nazlou (Helen) Danilidis

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

1. Northern Health should review their relevant falls risk mitigation strategies including relevant policies and procedures
2. 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
3. Implement and document purposeful rounding on every shift
4. Complete all risk screening assessments including delirium and cognitive impairment on EMR on every shift
5. Where possible limit bed moves for patients over 65 with increased confusion, as this increases their risk of falls
6. Highlight to nursing staff via huddles and email the importance of placing sensor mats according to manufacture guidelines