Finding into death of Patricia O'Connor

84y · Female·Multisystem organ failure related to complications from a fall resulting in hip fracture (operated)

Patricia O'Connor, 84-year-old woman with bipolar disorder, was admitted involuntarily to Sunshine Aged Persons Mental Health Unit on 15 August 2017 during a manic relapse. On 25 August, she fell and fractured her right femur while ambulating with a frame in the low-stimulus area despite being assessed as high falls risk. She underwent surgery on 27 August but her acute mania, severe agitation, and challenging behaviour made post-operative management extremely difficult. Staff could not administer necessary blood transfusion due to inability to obtain vascular access from her agitated state. She deteriorated with post-operative complications and died 7 September 2017 from multisystem organ failure. The coroner found care appropriate given the challenging circumstances, though noted Western Health's processes were not fully complied with as she wasn't transferred to an orthopaedic ward due to bed unavailability.