Non-inquest findings into the death of Mr G

84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delirium due to antipsychotic medication due to dementia of Alzheimer's type

An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency department with three falls and acute confusion requiring one-to-one nursing, he was discharged back to aged care on 18 August 2024. The coroner found the medical team failed to recognise delirium as the primary diagnosis and underappreciated how unwell the patient was. After a subsequent fall resulting in a fractured humerus, he was again discharged without admission. The coroner identified missed opportunities for hospital admission and inadequate communication between hospital and aged care staff. While the geriatrician's medication review was appropriate, the emergency department's failure to recognise delirium and properly assess the aged care facility's capacity to provide intensive nursing care contributed to the poor outcome.