Inquest into the Death of Webb, Violet
Deceased
Webb, Violet
Demographics
83y, female
Date of death
2009-11-09
Finding date
2013
Cause of death
Diffuse Alveolar Damage in a woman with recent leg fracture and Atherosclerotic Cardiovascular Disease
AI-generated summary
An 83-year-old woman with diabetes, cardiovascular disease, and mobility limitations fell from her bed while on a bedpan at an aged care facility, sustaining a compound ankle fracture. The registered nurse on duty had left her unattended on the bedpan with a commode nearby, contrary to care plan requirements for two-carer assistance with hoist use. While the fracture was surgically repaired, her pre-existing comorbidities prevented recovery and she deteriorated and died 17 days later from diffuse alveolar damage. The coroner found no lack of care, though the nurse did not follow the established safety system. Key lessons: maintain adherence to individualised care plans, particularly for high-risk transfers; anticipate complications when mobilisation constraints are not followed; and ensure consistent documentation of clinical findings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Fall from bed while on bedpan
- Non-adherence to individualised care plan requiring two-carer assistance with hoist
- Commode left in proximity to bed
- Pre-existing comorbidities: diabetes, cardiovascular disease, obesity, osteoporosis, poor mobility
- Fluctuating blood sugar levels and hyperglycaemia
- Compound ankle fracture with vascular compromise
- Inability to recover due to pre-existing medical conditions
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