Coroners Case  – First Impressions

Coroners Case – First Impressions

‘The risk of falls confronts every older person, in every aged care facility, in every country. Despite some gains in prevention, and better post-fall management, the harm from falls remains a major cause of injury and injury-related deaths in older persons and residents. It is also important to consider this in the context of the most recent release of the next draft by the Commonwealth Government concerning aged care quality standards. The general expectation is that this will be part of a package of legislative amendments to be tabled in Parliament later this month.

Case No: 2012 3130 Précis author: Carmel Young RNCCM, Department of Forensic Medicine, Monash University

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Clinical Summary
Ms Vv was a 76-year-old female who resided in a RACS located in a seaside town where she required high level care. Her past medical history included dementia, Parkinson’s disease, and anxiety. She had declining cognitive function with a hearing impairment and was nonverbal. One winter’s day, Ms Vv had an unwitnessed fall in her room at approximately midday. Upon finding her, the Personal Care Assistant (PCA) sought the help of a second PCA to get Ms Vv back to bed. As no registered nurse or state enrolled nurse (SEN) was on duty at that time, a SEN from another area of the facility was asked to review Ms Vv. The facility’s manager was also asked to review Ms Vv some time after the fall. The General Practitioner (GP) was then notified, and it was decided not to transfer Ms Vv to hospital, but to monitor her condition at the nursing home.

Four hours after the fall, Ms Vv’s family came to visit, found her in distress, and immediately asked for a reassessment. As a result of that second assessment another phone call was placed to the GP and Ms Vv was transferred via ambulance to the hospital. Imaging tests revealed a fractured C7 vertebrae, a fractured neck of femur, an acute subdural haematoma and a subarachnoid haemorrhage. After discussions with the family, Ms Vv was provided with comfort care and died five days later.

The cause of death following an external examination by the forensic pathologist  was determined to be complications of head and neck injuries sustained in a fall. The contributing factors were Parkinson’s disease, dementia and chronic subdural haematoma

When the family were advised that the coroner intended to close the case as a chambers finding (i.e. without holding an inquest), they raised concerns about the care and management post-incident. The coroner then decided to investigate the matter further and statements were obtained from staff at the RACS. These statements were given to the family to consider whether their concerns had been addressed. These documents included RACS progress notes along with the facility’s policy about falls assessment. The matter was listed as a mention/ directions hearing three years after the incident. As no firm conclusion was reached on the matter, the coroner listed the case for an inquest. The inquest was held over two days, four months later, and involved the RACS staff and provider as well as two general practitioners.

At the inquest, the first SEN who examined Ms Vv considered that she needed to go to hospital. The SEN was concerned about the ‘head strike’ and that Ms Vv’s pupils were pinpoint. The SEN said that her original notes “went missing”, but as she had kept her own notes she was able to make retrospective notes when asked to go into the facility the next day. The RACS manager who attended noted that Ms. Vv was smiling at her and did not appear to be in pain. She explained that the curtains had been pulled closed in the room to check the pupil reaction and she found the pupils were brisk and reacting to light.The RACS manager checked the range of movement of Ms Vv’s legs and arms, and was told by the SEN that Ms Vv was usually quite stiff. The RACS manager was not aware that Ms V was on aspirin but was told of the possible head strike.The RACS manager also said that she had not made any contemporaneous notes of her examination and assessment, nor of her discussion with the GP. The coroner noted that observations were undertaken for only one hour after the fall. The nurse who was asked to perform the observations was not told how long to do them for, and so stopped after one hour. The GP at the inquest stated that if he was told of the fall and head strike he would have asked that Ms Vv be transferred to hospital for further investigation.

Coroner’s Comments and Findings
The coroner stated that the fall with obvious head strike should have resulted in a thorough examination and assessment being undertaken by, at least a divisional 1 registered nurse, or even more appropriately by a medical practitioner. The coroner was critical in the absence of a formal post-incident review. The coroner stated that it would have been most helpful if the observations/ recollections of the staff involved had been sought and documented shortly after the incident. The issue of the adequacy, or more importantly, the inadequacy of documentation in the progress notes would have been obvious at that time. The coroner recommended the RACS formalize and implement a comprehensive, robust internal review process to examine their approach to this event.

Editor’s Note
A detailed root cause analysis (RCA) following this type of incident assists in identifying the gaps in care and what improvements need to be made in the future. It is worthwhile looking back to our March 2013 RAC-Communiqué, which explores the utility of RCA and has an interesting commentary on the nature of evidence and recall. These concepts are still applicable today.The past issue also highlights the importance of using information and lessons from other RACS to improve our service. The need for better documentation and improved responsiveness in RACS are recurring themes familiar to our long-time subscribers. These themes are once again pertinent in this case, and feature in the proposed new aged care standards, specifically, in “Initial and ongoing resident assessment and care planning to inform the delivery of safe and effective care” (Proposed Standard 2.2) and “Deterioration or change of a consumer’s function, capacity or condition is recognised and responded to in a timely manner” (Proposed Standard 3.5).’

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Authored by: The Communiques

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