Coroner's Finding: KOLAN Zygmunt

91y · Male·intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating recurrent falls on a background of Alzheimer's dementia

A 91-year-old man with Alzheimer's dementia died from intracranial haemorrhage following recurrent falls at a nursing home. He had multiple comorbidities including metastatic prostate cancer, metallic aortic valve replacement requiring anticoagulation, and pacemaker. He suffered two significant falls within two days while in respite care, the second causing bilateral subdural haemorrhages and other traumatic injuries. Management of anticoagulation was complicated by high clot risk from the valve versus bleeding risk from falls. The coroner found care at both hospital and nursing home was appropriate, with reasonable protective measures in place including frequent monitoring, floor mats, and low bed settings. No deficiencies in clinical management were identified.