Finding into death of David Sheppard

76y · Male·Intracranial Haemorrhage Secondary to Blunt Head Trauma (Fall) in the Setting of Chronic Myeloid Leukaemia

A 76-year-old man with newly diagnosed chronic myeloid leukaemia in blast crisis was admitted to hospital with sepsis and pancytopenia from chemotherapy. He suffered multiple falls while confused from sepsis, sustaining a subdural haemorrhage that progressed despite maximal medical therapy. The coroner found no clinical mismanagement caused or contributed to death. However, the falls risk assessment tool was not completed correctly and did not document his recent fall history, failing to meet the hospital's own falls prevention guidelines. While more detailed falls risk documentation would not have changed the outcome, it would have better addressed family concerns. A systemic issue was identified: PBS regulations causing delays in accessing Imatinib Mesylate for acute leukaemia patients, though expedited treatment would only have controlled rather than cured the disease.