Deceased
CHRIS CHRISTODOULOU
Demographics
82y, male
Coroner
Coroner John Olle
Date of death
2009-03-09
Finding date
2010-08-26
Cause of death
Intracranial haemorrhage secondary to blunt force trauma (fall)
AI-generated summary
An 82-year-old man resident in a nursing home died from intracranial haemorrhage following a fall. He sustained two falls on 7 March 2009; the first was unwitnessed at 8.24am. When examined after a second fall at 7.35pm, nursing staff performed normal neurological observations and did not call a doctor. Critical system failures included: inadequate handover between shifts meant staff were unaware of the first fall; the nurse who examined him after the second fall did not know about the morning fall and stated she would have called a doctor had she known. The coroner found that while neurological observations were normal and there was no obvious injury, the failure to contact a GP after a fall in an elderly resident, compounded by poor communication systems, represented a missed opportunity for assessment. The facility subsequently implemented mandatory handover processes and a policy to call GPs for all falls.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
FORM 37 Rule 60(1)
FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1474/09
Inquest into the Death of CHRIS CHRISTODOULOU
Delivered On: 26 August 2010
Delivered At: Hearing Room, Level 1, 436 Lonsdale Street, Melbourne 3000 Hearing Dates: 6 August 2010
Findings of: JOHN OLLE
Representation: John Carmody for Devinder Singh
Neil Murdoch for Meadowglen Nursing Centre Place of death: Northern Eospital, 185 Cooper Street, Epping 3076
PCSU: Sergeant ‘lracey Weir
1 of 5
Rule 60(1)
FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008
Court reference: 1474/09
In the Coroners Court of Victoria at Melbourne 1, JOHN OLLE, Coroner
having investigated the death of:
Details of deceased: Surname: CHRISTODOULOU First name; = CHRIS Address: Meadowglen Nursing Home, 202 McDonalds Road, Epping 3076
AND having held an inquest in relation to this death on 6 August 2010
at Melbourne Magistrates Court find that the identity of the deceased was CHRIS CHRISTODOULOU
and death occurred on 9th March, 2009
at Northern Hospital, 185 Cooper Street, Epping 3076
from
la. INTRACRANIAL HAEMORRHAGE SECONDARY TO BLUNT
in the following circumstances:
Nursing Home, Epping.
A coronial brief has fully addressed the circumstances of death, At inquest T received evidence from RN2 Devinda Singh, RNI ‘Thokozani Sithole, RN1 Lillian Nzenza and Yvonne Bull, Director of Nursing Meadowglen Nursing Centre.
Tam satisfied the circumstances of death of Mr Christodoulou have been fully addressed.
Chronology
12 January, 2009 Mr Christodoulou admitted as a permanent resident to the Meadowglen Nursing Home.
2o0f 5
14 January, 2009 Decision made to allow Mr Christodoulou access to mainstream unit during the day. Mr
Christodoulou required to slecp in the dementia specific unit of an cyening.
12 February, 2009 Dr Giapoakis, General Practitioner, prescribed medication to address Mr Christodoulou’s
wandering behaviour.
19 February, 2009 Dr Giapoakis reviewed Mr Christodoulou following observed unsteadiness on his feet and a
subsequent fall.
7 March, 2009
“e@ At approximately 8.24am, Mr Christodoulou was observed by nursing staff following an
unwitnessed fall. Nil injuries observed and Mr Christodoulou was able to walk without signs of pain.
® At approximately 7.35pm, Mr Christodoulou was found by a staff member lying on the floor
beside his chair, RN2 Singh was alerted and attended Mr Christodoulou who was in the process of getting up. With assistance, Mr Christodoulou walked to his room. RN1 Nzenza
was contacted and reviewed Mr Christodoulou.
4, RN1I Nzenva knew Mr Christodoulou. She noted he was responding in a normal fashion.
Neurological observations performed by her were within normal range. RN1 Nzenza directed RN2 Singh to make appropriate entries in the progress nursing notes. She instructed a personal care assistant (PCA) to monitor Mr Christodoulou.
5, RN2 Singh concluded his shift at 8.00pm. He informed RN1 Nzenza that he had left message for the family. Mr Christodoulou was sleeping at that time,
Throughout the evening RN1 Nzenza performed regular neurological observations.
At approximately 5.30am, Mr Christodoulou was observed bleeding from the nose. Mr
Christodoulou was promptly conveyed by ambulance to the Northern Hospital.
Lessons Learnt
9, The facility has learnt valuable lessons following the death of Mr Christodoulou. Of
particular significance:
a) Inadequate handover process
The first fall on the 7 March was the subject of entry in the progress notes. At the lime, RNI Nzenza would receive a handover and subsequently appraise staff on duty. RN2 Singh should have reccived a hand over from RN1 Nzenza at the commencement of his
4pm shitt.
Regrettably, RN1 Nzenza did not receive a hand over on the 7 March, 2009.
Accordingly, RN2 Singh commenced his shift without hand over. Having not read the
progress notes, RN2 Singh was unaware of the fall earlier that day.
b) RNINzenza was unaware of the fall, earlier that day
When RN1 Nzenza was called to examine Mr Christodoulou followmg the second fall, she was unaware he had had a fall carlier that day. In evidence explained had she known, a General Practitioner would have been called.
RN1 Nzenza explained: “The thing that we didn’t do on that day was call a doctor. We didn’t call a doctor an this occasion because there was no obvious injury to Chris. Afier Chris died, we call the doctor every time a patient has a fall, whether it is witnessed or not."
Further: “When I finish my shift, [ hand it over to night shift exactly what had transpired. ‘The night shift were not aware of the first fall either because T was unaware and could not pass this information on to them."
Communication problems did not reflect a lack of professional care
12, The care and attention offered Mr Christodoulou by facility staff was caring and professional. The shortcomings identified are not causative of death.
AofS
Christodoulou to hospital.
l4. Mr Christodoulou was monitored through oul the evening. Upon noting his deterioration, a
speedy hospital transfer occurred.
The facility has implemented change
resident suffers a fall, a general practitioner will be called to attend.
‘inquest. | offer all family members my condolences.
Post Mortem Medical Examination
autopsy not be performed, Dr Lynch found the cause of death to be intracranial haemorrhage
secondary to blunt head trauma (fall).
Signature:
John Olle Coroner .
Date: 26 Augusy/2010
f é fi é j
ie ig
Sof 5
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
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.