Coronial
WAhospital

Inquest into the Death of Francis Robert Ward

Deceased

Francis Robert Ward

Demographics

90y, male

Date of death

2013-09-08

Finding date

2014-10-22

Cause of death

Pneumonia in a man with traumatic brain injury

AI-generated summary

Francis Robert Ward, age 90, died of pneumonia following traumatic brain injury sustained from multiple falls while imprisoned. He had numerous comorbidities including hypertension, renal impairment, and age-related frailty. A fall on 13 June 2013 resulted in a small subdural haematoma. A second significant fall on 17 August 2013 caused an acute subdural haemorrhage deemed unsuitable for neurosurgery. He deteriorated and developed aspiration pneumonia, dying in palliative care at Rockingham General Hospital on 8 September 2013. The coroner found medical care was adequate but noted a mattress beside the bed might have prevented the August fall, which could have been implemented when falls alarms were provided in July 2013. No systemic failures were identified; death was deemed accidental.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicineneurosurgerygeriatric medicinepalliative careforensic medicinecorrectional health

Error types

system

Clinical conditions

traumatic brain injuryacute subdural haemorrhagechronic subdural haematomapneumoniaaspiration pneumoniatranstentorial herniationfallshypertensionacute-on-chronic renal failureanaemiagastrointestinal bleedcoronary atherosclerosisrheumatoid arthritismultilevel spinal stenosisfirst-degree AV block

Procedures

CT scan of headgastroscopyvenous duplex scanpost-mortem examination

Contributing factors

  • Multiple falls from frailty and age-related comorbidities
  • Acute subdural haemorrhage on 17 August 2013
  • Prior subacute/chronic subdural collection from June 2013 fall
  • Age (90 years) and multiple comorbidities making neurosurgical intervention inappropriate
  • Aspiration pneumonia as complication of brain injury and palliative care
  • Delayed access to staff during falls due to locked infirmary cells
  • Lack of protective bedding at time of critical fall

Coroner's recommendations

  1. Consider implementation of protective bedding measures (mattress beside bed with bed pushed to wall) for high falls-risk patients in custodial infirmary settings, similar to practices in other healthcare settings, particularly when falls alarms are first provided
  2. Development of specific falls management policies for prison health services caring for elderly prisoners with multiple comorbidities
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