Inquest into the Death of Daniel

83y · Female·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.

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.