Coroner's Finding: Weily, Richard Maurice

85y · Male·Probable pneumonia following a hip fracture (comminuted fracture of right acetabulum) sustained in a fall at RFC. Significant contributing factors: ischaemic heart disease, dementia, and Parkinson's disease.

Richard Weily, 85, with Lewy-body dementia, Parkinson's disease, and cardiac disease, was admitted to Roy Fagan Centre (RFC) mental health facility on 13 June 2013 under Mental Health Act provisions for management of acute psychiatric symptoms including agitation, confusion, and suicidal ideation. While at RFC, he fell from bed on 7 July, sustaining a comminuted acetabular hip fracture. He was transferred to hospital for orthopaedic assessment but underwent palliative care given his age and poor prognosis. He died from pneumonia on 15 July. The coroner identified significant failures in RFC's falls risk management: assessment was delayed nine days post-admission, high falls risk was not recorded on Alert Sheets or ISPs, and no falls prevention strategies were implemented prior to the fracture. The coroner also found that GP Dr R.'s prescription of haloperidol was unwise in this patient but did not contribute to death. The coroner recommended RFC undertake comprehensive review of its falls risk assessment and management processes.