Coroner's Finding: Mitchelmore, Susan

70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, including delirium

Susan Mitchelmore, a 70-year-old woman with multiple comorbidities including COPD, ischaemic heart disease, diabetes, and bipolar disorder, was a resident in an aged care facility under a Mental Health Act Treatment Order. She sustained a neck of femur fracture from a fall despite appropriate falls prevention strategies in place. Following surgical fixation at hospital, her postoperative course was complicated by delirium, reduced oral intake, and respiratory compromise, leading to pneumonia. She transitioned to end-of-life care following appropriate family discussions. The coroner found falls prevention measures were suitable and her falls resulted from her impulsivity and failure to use mobility aids. No clinical errors or preventability issues were identified. The case highlights the challenges of falls prevention in cognitively impaired, impulsive residents despite comprehensive risk mitigation strategies.