Deceased
Nancy Muriel Hazell
Demographics
100y, female
Date of death
2022-06-30
Finding date
2023-04-03
Cause of death
frailty and fracture of the right neck of femur
AI-generated summary
Nancy Muriel Hazell, aged 100, was a long-term resident of an aged care facility with appropriate falls prevention measures in place including bed/chair sensors, call bells, and physiotherapy. She sustained an unwitnessed fall from her armchair on 25 June 2022, fracturing her right neck of femur. Despite orthopaedic surgery, her condition declined post-operatively and she died on 30 June 2022 from frailty and the hip fracture. The coroner identified that her chair sensor did not activate before the fall, which might have allowed staff intervention to prevent it. The facility had no explanation for the sensor failure. The key clinical lesson is ensuring that safety equipment in aged care is regularly tested and maintained to function reliably, as equipment failure can eliminate critical protective measures for vulnerable elderly residents at high fall risk.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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 Nancy Muriel Hazell Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Nancy Muriel Hazell.
b) Mrs Hazell was born on 12 January 1922 and was aged 100 years at her death.
She was widowed and, since 2014, she had been a resident at Uniting AgeWell Queenborough Rise nursing home in Sandy Bay. Although she was very healthy for her age, she had been slowly deteriorating physically and cognitively. Since the commencement of her residency at the nursing home, she had had a number of unwitnessed falls. She was subject to regular falls risk assessments and, in accordance with those assessments, falls prevention measures were put in place for Mrs Hazell by the nursing home. These prevention measures included a bed and chair sensor, a personal call bell pendant and a physiotherapy program for muscle strengthening.
On 25 June 2022 Mrs Hazell had an unwitnessed fall, apparently having left her armchair and then using her over-bed table as a walking aid before falling. Staff members discovered her on the floor, conscious and in significant pain. She was transported by ambulance to the Royal Hobart Hospital where she was assessed as having sustained a fracture to her right neck of femur (hip). She underwent orthopaedic surgery the following day but post-operatively her condition declined. Given her poor prognosis, a decision to treat her palliatively was made with her family and she passed away on 30 June 2022 in the Whittle Ward.
c) Mrs Hazell died as a result of frailty and a fracture of the right neck of femur.
d) Mrs Hazell died on 30 June 2022 at Hobart, Tasmania.
In making the above findings, I have had regard to the evidence gained in the investigation into Mrs Hazell’s death. The evidence includes: The police and hospital reports of death for the coroner; An opinion of the forensic pathologist regarding cause of death; Affidavits confirming life extinct and identification; Affidavits of a doctor and nurse from the Repatriation Hospital, who cared for Mrs Hazell; Affidavits of Penelope Brown and Elaine Hazell, daughters of Mrs Hazell; and Report, records and correspondence from Queenborough Rise nursing home.
Comments and Recommendations The falls prevention measures implemented by the nursing home for Mrs Hazell were appropriately responsive to her risk. However, one issue arising in this investigation is why Mrs Hazell’s chair sensor did not apparently activate before her fall, which may have prompted staff to enter her room to assist her and prevent her falling. The nursing home has provided information that there is no known reason why the alarm did not activate.
I recommend that Queenborough Rise nursing home takes any steps necessary to ensure that the chairs sensors in its facility are fully operational.
I convey my sincere condolences to the family and loved ones of Mrs Hazell.
Dated: 3 April 2023 at Hobart in the State of Tasmania.
Olivia McTaggart Coroner
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 …
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.