RHH cops flak over patient’s death

THE death of a 91-year-old woman who fell out of bed at the Royal Hobart Hospital could have been prevented if her risk of falling had been better assessed, a coroner has found.

The woman, known as Mrs F, fractured her left hip in the fall on December 5, 2015, and died three days later.

“Mrs F’s fall and its fatal consequences would, in all likelihood, have been avoided if the RHH had ensured that her falls risk was comprehensively assessed,” Coroner Rod Chandler wrote in his findings handed down yesterday.

Mr Chandler said Mrs F was a high risk for falls.

“This circumstance required the RHH to take all reasonable steps to minimise the risk of Mrs F falling and causing herself injury,” he said.

“However, it seems that the only steps in fact taken were to advise Mrs F not to leave her bed and to utilise the buzzer if she needed to do so, presumably so that she could be assisted to attend the bathroom.”

Mr Chandler said Mrs F’s cognitive state was such that it was highly unlikely she would remember and therefore comply with directions from nurses.

“Her safety demanded that other measures be taken and these, in the least, should have included a lowered bed, the provision of a floor mat and ideally the fitting of a bed sensor.

“The failure to employ any of these measures constituted a serious shortcoming in the standard of care required by Mrs F.”

Mr Chandler also pleaded with anyone who has been asked to assist a coronial investigation to do so as promptly as reasonably possible.

He said a report he asked the Tasmanian Health Service’s patient safety executive director to prepare was received seven months after the initial request.

Mr Chandler said the Health Service advised him of recommendations made after Mrs F’s death. They were to increase the use of the hospital’s falls risk assessment tool, direct observations of patients with a high risk of falling, regular auditing of the assessment tool, and educating the staff about falls assessment.