Deceased
Robert Edward Cash
Demographics
89y, male
Date of death
2022-07-13
Finding date
2023-02-22
Cause of death
peri-prosthetic fracture of right femur
AI-generated summary
89-year-old man resident in aged care suffered an unwitnessed fall in his bathroom, sustaining a peri-prosthetic right distal femur fracture. He was assessed as high falls risk. Post-operatively his condition deteriorated with decreased consciousness; palliative care was adopted and he died 7 days later. The coroner noted that a sensor alarm was unavailable in his room at the time of the fall, though acknowledged this may not have prevented the fall. The coroner recommended installation of sensor alarms for high-risk residents. Key lesson: ensure falls prevention equipment is available and functional for residents identified as high falls risk in aged care settings.
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Specialties
Error types
MAGISTRATES COURT of TASMANIA
CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Robert Edward Cash Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Robert Edward Cash.
b) Mr Cash was born on 3 March 1933 and was 89 years at his death. He was married and was a resident of Regis Aged Care nursing home in Warrane. He suffered numerous medical conditions and, in the period before his death, was declining cognitively and was generally unsteady. He was assessed by the nursing home as having a high falls risk. On 6 July 2022, Mr Cash was found on his bathroom floor, having suffered an unwitnessed fall. He was transported to hospital and found to have a peri-prosthetic right distal femur fracture for which he underwent surgery. His condition deteriorated post-operatively with a decrease in consciousness. A palliative approach was adopted in consultation with his family and he passed away peacefully on 13 July 2022.
c) Mr Cash’s cause of death was peri-prosthetic fracture of right femur.
d) Mr Cash died on 13 July 2022 at Royal Hobart Hospital in Tasmania.
In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Mr Cash’s death. The evidence includes: The police and hospital reports of death for the coroner; Affidavits confirming life extinct and identification; Report of the forensic pathologist regarding cause of death; Affidavit of Joan Cash, wife of Mr Cash; Affidavit of Maree O’Neill, daughter of Mr Cash; and Report, correspondence and records from Regis Aged Care.
Comments and recommendations I comment that, at the time of Mr Cash’s fall, the nursing home did not have a sensor alarm in his room due to this device being unavailable at the time. Although the nursing home had in place all other appropriate prevention measures, a sensor alarm may have alerted staff to Mr Cash moving within his room. It is difficult to say, however, that such a measure would have prevented his fall.
I recommend that Regis Aged Care Pty Ltd install sensor alarms in the rooms of residents where the falls risk assessments warrant this measure.
I convey my sincere condolences to the family and loved ones of Mr Cash.
Dated: 22 February 2023 at Hobart Coroners Court in the State of Tasmania.
Olivia McTaggart Coroner
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