Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humerus

Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged against medical advice prematurely, then re-admitted after re-fracturing the same arm. During his hospital stay, he suffered a third fall on 3 February 2023 injuring his left humerus. Clinical lessons: falls risk assessment should occur at admission, not after the first fall. Delirium assessment was inadequate and was a significant contributing factor. A Patient Safety Assistant was unavailable at the time of the preventable fall. While his death could not ultimately have been prevented given his poor baseline state, the fall hastened his decline. The coroner commended the health service for implementing improved falls risk screening tools and prevention strategies hospital-wide.