Coroner's Finding: McNeair, Jacqueline

79y · Female·subdural haematoma following mechanical fall with head strike

A 79-year-old woman with multiple comorbidities including diabetes, peripheral neuropathy, and previous partial foot amputation fell backwards in a hospital toilet on 23 November 2018, striking her head on a sink and floor. She sustained a catastrophic subdural haematoma and died 11 days later. The coroner found the care provided was adequate and appropriate, with fall risk appropriately assessed at level two requiring one-staff assistance. While the patient's progressive instability and peripheral neuropathy increased fall risk, the coroner accepted expert opinion that falls in elderly hospitalised patients with multiple risk factors are often not reasonably preventable. No clinical errors or supervision failures were identified. The fall was deemed unavoidable despite complex medical needs.