48 results
92y · Female·Complications of a fractured left femur (operated), sustained in a fall
Dorothy Lorraine Boyle, aged 92, died from complications of a left femoral fracture sustained in a fall at an aged care facility. She fell while attempting to push out a wandering dementia-affected resident who had enter…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…
77y · Male·Hypothermia
Raymond Speechley, aged 77 with dementia, absconded from an aged care secure unit on 7 July 2016 and died from hypothermia in bushland. Critical systemic failures at the facility included: failure to identify him as an a…
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
86y · Female·subdural haemorrhage due to or as a consequence of a fall
Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…
97y · Male·Complications of a fractured left neck of femur (operated), sustained in a fall
A 97-year-old man with vascular dementia, visual impairment, gait instability and multiple falls risk factors fell during a supervised outing from his aged care facility and sustained a fractured neck of femur. Despite b…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…
Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…
88y · Male·left frontal lobe haemorrhage due to a fall
Mr Edward Davis, an 88-year-old man with epilepsy, stroke, dementia and on anticoagulation therapy, fell onto a Stand-Up Lifter positioned directly in front of him while waiting for a second staff member to operate it. H…
91y · Female·pelvic haematoma arising from a fracture of the neck of the left femur sustained…
A 91-year-old woman with dementia, emphysema and cognitive decline was admitted to hospital after a fall. She was assessed as high falls risk but inadequate fall prevention measures were implemented—only verbal advice to…
82y · Male·Trauma related intracerebral haemorrhage
An 82-year-old man with dementia, cerebellar ataxia, and mobility limitations fell from his wheelchair down three concrete steps (480cm drop) while attending a hearing aid appointment at an off-site clinic. He sustained …
89y · Female·pneumonia and acute renal failure following a fractured right femur due to a fal…
Margaret Evalina Bugg, aged 89, died from pneumonia and acute renal failure following a spiral fracture of her right femur sustained during a fall from a stand-up lifter on 17 December 2015. A mobility assessment in Octo…
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…
84y · Male·Complications of large right subdural haematoma
An elderly man with cognitive impairment and multiple comorbidities fell out of bed at an aged care facility while an assistant in nursing (AIN) was absent obtaining equipment. The AIN had raised the bed to facilitate us…
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
85y · Female·neck injury (cervical spine fracture) as a consequence of a fall
Mrs Florence Thomas, 85, died from cervical spine fractures sustained when she fell from a toilet chair at her nursing home. She had multiple documented falls and explicit care plan instructions never to be left alone on…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
Fourteen elderly residents died in a deliberately-lit fire at Quakers Hill Nursing Home on 18 November 2011, set by drug-dependent nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly i…
76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …
76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …
82y · Female·fat embolism syndrome and bronchopneumonia following nail fixation of bilateral …
An 82-year-old woman with severe dementia and marked osteoporosis died from fat embolism syndrome and bronchopneumonia following surgical fixation of bilateral femoral fractures. The fractures occurred on 10 September 20…
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