Complications following fracture and surgical repair of the left hip in an elderly lady with underlying chronic lung disease and valvular heart disease. Specifically: progressive respiratory failure with probable pneumonia on a background of chronic interstitial lung disease, worsening cardiac failure with underlying valvular heart disease and mild coronary artery disease, and acute on mild chronic renal impairment.
AI-generated summary
Nola Inez Daniel, 83, died from complications following a hip fracture and subsequent surgery at Bunbury Regional Hospital on 7 January 2010. She sustained a fractured left neck of femur during a fall at Regis Forrest Gardens aged care facility on Christmas Day 2009, but the fracture was not diagnosed until 16 hours later. After the fall at 7.30pm, nursing staff failed to call a doctor or adequately document the incident. The fracture was not identified until the following morning when the deceased presented with obvious pain, shortened and rotated leg, and facial bruising. She underwent hip repair surgery on 29 December but developed post-operative pneumonia and respiratory failure. The coroner found the care at Regis Forrest Gardens fell below required standards, particularly in failure to examine the deceased following her fall and communicate findings between shifts. However, Regis subsequently implemented significant improvements to falls management, incident reporting, and shift handover procedures.
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Specialties
geriatric medicineorthopaedic surgeryintensive careemergency medicine
Error types
diagnosticcommunicationsystem
Clinical conditions
fractured left neck of femurintracapsular fracture of left femoral neckosteoporosispulmonary fibrosismitral regurgitationpneumoniarespiratory failurecongestive cardiac failurecoronary artery diseaserenal impairment
Procedures
left hemiarthroplastyfemoral nerve blockx-rayechocardiogram
Contributing factors
Failure to diagnose fractured left neck of femur at time of fall
Failure of nursing staff to call doctor after fall at 7.30pm on Christmas Day
Inadequate documentation of fall by Nurse Meyer in progress notes
Inadequate communication and handover between nursing shifts
Failure to identify hip fracture despite significant pain, weight-bearing difficulty, and facial injury consistent with fall
Delay of 16 hours between fall and hospital admission
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