Inquest into the Death of Sweet
Deceased
Zenobia Enid Sweet
Demographics
90y, female
Date of death
2002-05-30
Finding date
2005-05-16
Cause of death
Intracerebral haemorrhage
AI-generated summary
Zenobia Enid Sweet, a 90-year-old woman with mild dementia, was admitted to Sir Charles Gairdner Hospital in April 2002 for surgical repair of a fractured femur. She was rehabilitating on Ward G51 (orthopaedics) with a goal to regain independent mobility so she could return to her aged care hostel. On 18 May 2002, during a shower, enrolled nurse Jennifer Zammit left the deceased leaning on a Zimmer frame without close supervision to locate a commode chair that had been removed from the bathroom. The deceased collapsed backwards, striking her head and sustaining an intracerebral haemorrhage. She was managed conservatively and died on 30 May 2002. The coroner found the death was accidental and highlighted systemic failures: ambiguous terminology around "Stand By Assist" supervision requirements, inadequate supply of commode chairs (only six for 30 patients), and lack of communication between nursing staff about equipment location. Recommendations focused on clarifying supervision terminology, ensuring adequate equipment supply, and improving inter-staff communication about equipment use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Elderly patient with dementia and complex medical problems
- Inadequate supervision during mobilisation - patient left leaning on Zimmer frame without close support
- Ambiguous interpretation of 'Stand By Assist' supervision protocol between physiotherapy and nursing staff
- Shortage of commode chairs on the ward (only six chairs for 30 patients)
- Missing commode chair - unclear who removed it or when
- Lack of communication between nursing staff about equipment availability
- Patient not mobilising at time of collapse but left unassisted
- Nurse made split-second judgment in non-emergency situation due to equipment shortage
Coroner's recommendations
- Those responsible for equipment on Ward G51 should examine the need for specific types of chair and review whether they are adequately provided
- Nurses responsible for particular groups of patients should check with each other regarding their time tabling for use of equipment items
- Clarification and education needed on the term 'Stand By Assist' to standardise its meaning between physiotherapy and nursing, with notation such as 'Z+1' or 'Z+2' to indicate Zimmer frame plus one or two people assisting, and use of abbreviations for 'close' and 'independent' supervision
- Education needed for nursing staff regarding communication between nurses about what their intentions are with pieces of equipment
- Implementation of improved fall risk assessment tools (Risk Management Tool for prevention of falls)
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