Coroner's Finding: VOIVODICH Guido

84y · Male·general inanition on a background of end-stage dementia and a fractured neck of femur (operated)

84-year-old man with end-stage dementia died from general inanition following a fractured neck of femur sustained while under a Level 2 Inpatient Treatment Order. He was admitted in January 2019 with confusion and agitation in extreme heat, requiring sedation and restraint. On 28 March 2019, he fell while sitting on a bed during blood pressure monitoring, sustaining a left neck of femur fracture. Surgery occurred 72 hours after anticoagulation ceased. Post-operatively he declined despite physiotherapy attempts, becoming bed-bound with poor oral intake. The coroner found the fall circumstances not suspicious, care was appropriate, and no recommendations were made. Clinical lessons include careful risk assessment for falls in sedated elderly patients with dementia, consideration of rehabilitation potential pre-operatively, and appropriate transition to palliative care.