Coronial

210 results for falls risk

QLDaged care2024-12-10

Non-inquest findings into the death of Mr O.

79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…

A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate fal…

geriatric medicineemergency medicinediagnosticmedicationaspirin
VIChospital2021-11-30

Finding into death of Eileen Violet Smith

88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants

…a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a documented falls management plan requiring two-person assistance. The fall occurred because staff were implementing individ…

rehabilitation medicineneurosurgeryproceduralcommunication
TASaged care2023-08-07

Coroner's Finding: Colpo, Dario

92y · Male·left haemothorax and rib fractures resulting from a fall at a residential aged c…

…n with multiple comorbidities (cardiac failure, COPD, chronic renal failure, diabetes) and documented high falls risk sustained a fall at a residential aged care facility on 12 May 2021, resulting in left haemothorax an…

geriatric medicinephysiotherapysystemproceduralrivaroxaban
SAaged care2021-06-30

Coroner's Finding: KOLAN Zygmunt

91y · Male·intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating r…

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 val…

geriatric medicineneurosurgerywarfarin
TASaged care2025-01-24

Coroner's Finding: Sheedy, Alan Noel

86y · Male·Traumatic closed head injury suffered in a fall

…ed in a fall at a residential aged care facility. He had been admitted for respite care following previous falls and was assessed as moderate falls risk with appropriate prevention strategies implemented. On 6 December …

geriatric medicineneurologylevetiracetam
WAhospital2014-10-22

Inquest into the Death of Francis Robert Ward

90y · Male·Pneumonia in a man with traumatic brain injury

Francis Robert Ward, age 90, died of pneumonia following traumatic brain injury sustained from multiple falls while imprisoned. He had numerous comorbidities including hypertension, renal impairment, and age-related …

emergency medicineneurosurgerysystem
VICaged care2010-08-28

Finding into death of Patricia Mary Cook

85y · Female·Complications of subdural haematoma (evacuated), secondary to fall, contributed …

…ry and did not call a doctor or ambulance, allowing 4 hours to elapse before she collapsed. The facility's Falls Policy was ambiguous and permitted staff discretion not to notify doctors if residents appeared well, refl…

geriatric medicineneurosurgerycommunicationsystemwarfarin
VICaged care2019-03-19

Finding into death of Anthony Charles Debono

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…

geriatric medicineorthopaedic surgerysystemcommunication
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

… Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged against medic…

orthopaedic surgerygeneral medicinesystemdelay
NThospital2016-09-01

Inquest into the death of Kerry James Murphy

73y · Male·Acute subdural haematoma

…'s overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors—yet no falls risk policy existed in ED. After cardiac monitoring was removed, he mobilised unsuperv…

emergency medicinecardiologysystemcommunicationblood thinners
TASaged care2023-04-14

Coroner's Finding: Taylor, Irene Barbara

99y · Female·pneumonia due to a fractured right neck of femur (hip) sustained in a fall

…tia resident in aged care fell and sustained a right femoral neck fracture. Despite being assessed as high falls risk with multiple prevention measures in place, she was not wearing hip protectors at the time of the fal…

geriatric medicineorthopaedic surgerysystem
VICaged care2023-05-15

Finding into death of Nickolaos Vlahos

92y · Male·Head and neck injuries sustained in a fall in a man with multiple co-morbidities

A 92-year-old man with dementia, multiple comorbidities, and a documented high falls risk died from head and neck injuries sustained in a fall at an aged care facility. He had experienced six…

geriatric medicinesystemcommunication
NSWaged care2011-05-20

Coroner's Finding: Iris Conyngham

91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…

…dmitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 45 minutes before be…

geriatric medicineproceduralcommunication
VIC2019

Finding into death of Geoffrey Joseph O"Neill

91y · Male·Head injuries sustained in a fall

…tres, and sustained an intracranial haemorrhage not amenable to surgical intervention. O'Neill had relevant risk factors including age, previous falls in the prior two years, use of a walking stick, and cardiac history. …

SAaged care2025-08-28

Coroner's Finding: Andrysik, Anne Carol

80y · Female·Fractured left neck of femur on a background of rectal carcinoma and dementia

… of femur sustained during a fall in her aged care facility's memory support unit. She had sustained three falls over 25 days; the final fall on 24 September 2022 resulted in the hip fracture. In accordance with her Adv…

geriatric medicinegeneral practicenorspan patch
TASaged care2024-09-27

Coroner's Finding: Webberley, Patricia

87y · Female·pneumonia following complications from a fractured left wrist sustained in a fal…

…s appropriate. However, the nursing consultant identified systemic issues at the RACF including inadequate falls risk documentation, insufficient hourly checks on night shift (2+ hours between checks versus required hou…

geriatric medicineorthopaedic surgerysystem
NSWaged care2016-10-20

Inquest into the death of Savvas Epsimos

84y · Male·Complications of large right subdural haematoma

… absent obtaining equipment. The AIN had raised the bed to facilitate use of a patient lifter, contrary to falls prevention policy requiring low bed positioning. No crash mats were present. When discovered, the AIN move…

geriatric medicineemergency medicineproceduralcommunication
VIC2022-02-03

Finding into death of Wayne Myhill

54y · Male·Neck injuries sustained in a fall - fracture of the fifth cervical vertebra (car…

…ed repeatedly at night (9-10 times per night). The disability support service failed to implement enhanced falls prevention strategies despite these clear warning signs, such as increased night staffing or motion-sensor…

neurologygeneral practicesystemdelaylamotrigine
TASaged care2025-06-13

Coroner's Finding: de-identified OQ -2

84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…

…ntia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acute hospital, but this critical need was not communicated duri…

geriatric medicinerehabilitation medicinecommunicationsystem
TASaged care2022-10-04

Coroner's Finding: Mundy, Gilbert Raymond

69y · Male·Chronic obstructive pulmonary disease, congestive cardiac failure and injuries s…

A 69-year-old man with severe COPD, congestive cardiac failure, epilepsy and high falls risk died following a fall from his motorised scooter at a post office. He had left his nursing home alone…

geriatric medicineemergency medicinesystem

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