Coroner's Finding: de-identified KW

87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right distal femur caused by several falls at home

An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during rehabilitation at a district hospital, developing severe malnutrition over 4-5 weeks with 7.1kg weight loss despite documented swallowing difficulties (Zenker's diverticulum). No definitive nutritional support plan was implemented early. She developed a spontaneous thigh haematoma in her malnourished state and died from bleeding complications. The coroner found malnutrition was a contributing factor. Key lessons: earlier recognition that rehabilitation was unrealistic; timely transfer back to tertiary hospital for enteral nutrition; earlier goals-of-care discussions; and improved nutritional assessment protocols at district hospital level.